dextromethorphan
-otc antitussive
-dosage to tx cough = 20-30mg per dose
-been shown to alleviate pain at doses 60+mg
-no way i couldve known the pain thing unless ask provider...cuz not in drug book. cool the nurse already asked and told me. acutally she gave me full report since i missed the change of shift report. cool x2.
oxymizer (i think thats what they called it. classmate's pt)
-looks like nasal cannual xcept its high flow. 10 lpm. sounds hard on the nose?
pulse ox
-leave on for 30-45secs at least
-if low, ask pt to deep breathe. watch spo2 shoot right up.
Protonix (pantoprazole)
- tx gerd/hypersecretions
-proton pump inhibitor: inhibits gastric acid secretion.
-"prazoles" = proton pump inhibitors. eg, omeprazole, pantoprazole, etc.
hydromorphone (Dilaudid)
-was able to give, despite allergy to morphine. no x-sensitivity?
-1.5mg IV = 10mg IV morphine. >> more potent
-duration via IV = 2 hrs. pt needed it every 2 hrs.
-induces sedation. major sleepiness is sidefx everytime i've ever seen this.
-burns veins when given iv. trick learned: dilute it into 5mL NS. then administer slowly over a minute. easier to control rate of 5mL then 1mL. (used 1mg=1mL). oh yeah flush w ns b4 n after.
pancreatitis
-sx incl: epigastric pain (pt's complaint, along w diarrhea, which brought her to the er)
-acute & chronic forms
-both forms involve inappropriately activated enzymes
-will have elevated amylase and lipase
-in men: assoc w alcoholism, tauma, peptic ulcer, poor prognosis (pt was female, and not etoh abuser)
-tx includes going npo (pt was on liquid diet)
-care incl pain, n/v, etc. (pt said appetite lil bc pain, nausea, drowsy)
crohn's dz
-part of inflamm bowel dz (ibd), along with ulcerative colitis
-most common in caucasians and ashkenazi jews, appearing most frequently during teens-early30s or in the 50s (pt was mid30s...and said had some gi condition..forget which...for the last 2 yrs).
-aka regional enteritis aka granulomatous colitis
-chronic inflamm of any part of gi tract (usu terminal ileum) extending through all layers of the intestinal wall
-cause unknown
-s/s incl: steady pain RLQ, cramping, diarrhea (these r sx pt had. when i assx pain, it was sharp pain. but whoever assx the prev 2 days doc'd cramping pain. but then again pain i assx, was epigastric...prbly r/t pancreatitis).
blood transfusion, post-op knee (other pt)
-device drains blood, u empty blood from that container into iv bag, then hang that iv bag and infuse it back into pt (thru reg iv catheter, not back into the knee specifically) along with ns
compression stockings
-my pt had elastic stockings (supposedly not used much these days)...dvt prophylaxis bc recent colon resection
-blood transfusion guy had other kind that wrap around with velcro and are inflated with some sort of electric pump.
head to toe assx
-hand push/pull: if pt has iv in hand veins, gotta find another way bc it will be painful for them!!
-gotta remember to listen to apical after lung sounds! just keep steth on....listen lungs-heart-ab b4 taking it off...faster!
-make sure they know hob coming up. not just height of bed!
clinical instructors (all instructors, rly) here are so much better than at prev program. they actually use clinicals as teaching/learning opportunities...during clinicial, as well as pre- and post- conf. imagine that!!
p.s. coolest, most rebellious, punkish, stylish rn uniform ever: this dykish looking nurse wore a grayish top, grayish, nearly form-hugging, camo pants, black shoes that kinda looked like boots (but werent), black fanny pack that was nothing special but just lookd tuff w that outfit, bracelets n rubberbands on one hand, triple hoop rings in each ear, dark hair that kinda came up in a messy faux hawk type thing that was dyed blue at the top. it worked. maybe one day i will push the limits with my uniform...
Tuesday, June 22, 2010
Tuesday, June 15, 2010
clinical 6/15: 2.5 hour code
i'd like to write something great that captures the moment but meh i got too much shit to do. n if i put it off for later, ill never get around to writing about it. so a rambling, hurried, half-ass post will have to do...
so on the way back from the multidisciplinary meeting, er nurse c tells our clinical instructor that there is a code in the ER, send over a couple students. i was grazing behind at the back of the group, still behind the corner when he told us this. but i heard it. and quickly turned the corner rt in his line of view and practically started jumping up and down pointing at myself "pick me pick me pick me pick me pick me pick me pick me!" ok i wasnt literally jumping but i was changing levels at my knees. lol.
picked. yes!
so me and my classmate (who i wouldnt peg as the er "type") follow er nurse c down to the er.
upon getting there, there's talk at the nurses station (or whatever u call it in the er) that the pt might not make it in. i sorta felt like a jerk for being disappointed. i wasnt disappointed bc he died. or because i missed an opportunity to help save his lfie. theres nothing wrong with that. no, was disappointed bc i wouldnt get to do cpr and the code n stuff.
so we hang out for a while. saw how everyone gets ready for the code. how they position stuff in the big room to makee space. how RTs are on standby with their bags and machines and stuff. how the ekg tech and whoever else are on standy with their machines and stuff. how the nurses are on standyb with their different roles: how the one nurse is in communication with the medics, how the recorder nurse is ready with her papers and clipboard, how the med nurse and whatever other nurses are hanging out in the area where they would soon do most of there work.
how nurse c had these two cases of emergency meds ready on top of a....was it a bed it was on top of? i dont remember. (nurse c had me and the classmate open the plastic breakaway things keeping the cases shut by twisting them). one case was just like multiple compartments of epi, atropine, both prefilled in syringes built for emergency administration it seems. also there was bicarb, glucose, and some iv bags, the contents of which i didnt ever know. the other case had stuff that was in vials. the only comaprtment i rember for sure was amiodirone (sp?), because we used it.
nurse c's role was to prepare the meds that are called out and hand em to whoever. i think it was nurses actually doing the administering. nurse c was cool. she let me fumble with withdrawing the amiodarone into the syringe. she gave the classmate an opportunity to do prepare a quickdraw atropine or epi or whatevr. she took time to explain stuff and let us try stuff. she was even pretty proactive about getting me in there to do cpr. :)
in all, the drugs we used throughout the code:
*epi
*atropine
saw first hand (multiple times!!) how atropine and epi could take a pt from a 20 or 40 pulse to 120 within seconds! did similar things for bp. dont remember how low it got, but i 220/160 sounds about rt for the highs.
*bicarb (na bicarobate? i dont remember)
will have to read up why was used. but when doc called for it, it was usually around the time he wanted atropine. didnt always call for them together, but when he wanted bicarb, he wanted atropine. always insisted on bicarb b4 atropine.
*heparin.
"5000 bolus." we used it bc doc suspected ischemic MI.
*amiadrione.
used it once. im vaguely familiar with it. know its a heart med. wanna say its for arrhythmias.
-a rectal aspirin (or something). which was weird. the guy shit his pants. not sure if it was b4 or after.
finally i hear someone announce they're here outside. not long after 4 or 5 firefight paramedics come in with a fat guy covered with tubes on top of a stretcher. he kind of stays to the back rattling off the history. there was a lot of confusion and unknowns about this pt xcept this 60 yo male has a history of seizures, and prior to 911 he told his wife he had chest pain, clutched his chest, started seizing, then stopped breathing. (i think). meanwhile there was a lot of impressive teamwork going on, everyone playing out different roles, calling out this and that. everyone was playing independently, and it all worked out and had an organized feel to it. if i didnt know any better, i wouldve guessed it was all orchestrated and rehearsed. it was like an antfarm or something.
meh im getting tired of writing and spending too much time on this. so just bunch of unorganized, barebones bulletpoints now.
-nurse putting in foley set up sterile field n stuff. but didnt come close to maintaining sterility. classmate told me to watch. wonder if she knew nurse's field was contaminated in 2 places.
-i kick ass at chest compressions. sorry dude, didnt mean to break your ribs or sternum or watever. but compressions were most effective when i rotated in. doc says 2 per second. theres this monitor where you can see chest compression rate/depth/etc. i was pretty steady and had the right depth. broke the chest during my second rotation when the compressions werent as deep as they had been during my first set. see it was a big guy who had big lungs i guess, so the doc wanted the compressions deep. i think it was kinda my hand placement the second time. during my first set, i kinda didnt want to stop. i could see that i was more effective than everyone else doing compressions. but i was afraid i would get tired and lose effectiveness during future sets, so i agreed to let others rotate in after i felt kinda tired. i was winded, sweating, and started to feel my triceps burning. rt teacher dood handed me a towel. lol.
-there sure were a lot of ups/downs when it came to vitals. theyd give drugs to boost em up, then they'd drop back down.
-pts blood glucose was like almost 300 but doc said no insulin, wanted pt to keep blood glucose as high as possible. asked nurse c, she said it was to give the guy extra sugar for his brain n stuff.
-there was talk several times questioning the quality of life this guy would have if he made it. early on there was lots of pessimism about his chances. i'm glad they didnt give up. ironically, i am pessimistic about his chances travelling by ambulance to wherever it is they transferred him to. we had to do a lot of shit there in the er.
-but pt had to get transferred to a better equipped er. i'm at a pretty small hospital. when i got back to the floor, the sitter for my pt, who is a new grad nurse waiting for her new grad program to start this summer, was surprised anything like this happened in this er. she said she once had to float down there for a week and it was "pretty chill," which is fine for her since she doesnt like dramatic er stuff anywyay. on another side note, listening to her and the dialysis guy (a nurse?) talk, i got to hear their opinions for which local hospitals are good to work for.
-early on nurse c said she dint think it would end well. doc was ready to give up pretty early on. but 2nd doc didnt want to, said he'd feel bad about doing that. when family showed up, they decided to keep goin.
-classmate was amped up on adrenaline well after the scene was over and we were out of the er. surprised me for a couple reasons. one, she said she wants to do er now because of the focus she felt during all this. i can relate to the focus thing btw but i wouldnt of guessed she was like that. i wouldve guessed it would be overwhelming for her. but i was also surprised bc she didnt get the hands on that i did, right there rotating in doing cpr (she kinda just watched from afar, and in fact seemed kind of nervous when she was asked if she wanted to do it, in fact she insisted i go do it...not once but multiple times), yet for me, it was just something new and cool to be part of. not to say, i didnt care if the pt made it...bc i did want him to make it and was glad when his pulse came back after my compressions. i've spent good times in about 4 ers in my time, even been in various "situations," mosly involving 5150, psych, and drugged out pts, but this was my first cpr code and i like it. er wasnt nearly as exciting as i thought itd be except for those few "situations."
-true story: before i decided to return to nursing school, i was going to do rt school instead because i heard its exciting. and thats what i told the rt students there, who were bagging and rotating in with the chest compressions. the one guy offered to let me rotate in for bagging. pts pulse came back tho. wouldnt mind bagging rt student chick.
-the only emotionally arousing part for me was when the family showed up and i saw what mustve been the wife crying right outside the doorway after they shoo'd the nonessential peeps out of the room. actually it was more what i think mustve been the daughter that set me off. i had to look away everytime i saw her crying. (side note: the only time i came close to feeling that way was when i was in the other program following the home hospice nurse when we sat down with the early-20s-something yo daughter of a patient who the hospice nurse believed was on his way out. er daughter experience was much more intense tho).
-one of nurse c's responsibilities was to talk to the family. i asked if she did it bc was a responsibility or just thats the kind of thing that she gravitates to. she said both. but yes, is responsibility.
k, ill just wrap it up cuz im writing like crap now.
will just say my pt on the floor was pretty interesting too. 91 yo who looks 50. his secret is scotch and water almost daily. haha. dialysis. edema. pacemaker. defibrillator. cataracts returning after lasiks. interesting skins. low ass bp. like 70/50, but denies dizziness. hx crf, pna, hyperlipidemia, diverticulosis, and a bunch of stuff. if i had time to learn all his issues, tx, and meds, i'd learn alot. too bad i dont.
cool clinical day.
so on the way back from the multidisciplinary meeting, er nurse c tells our clinical instructor that there is a code in the ER, send over a couple students. i was grazing behind at the back of the group, still behind the corner when he told us this. but i heard it. and quickly turned the corner rt in his line of view and practically started jumping up and down pointing at myself "pick me pick me pick me pick me pick me pick me pick me!" ok i wasnt literally jumping but i was changing levels at my knees. lol.
picked. yes!
so me and my classmate (who i wouldnt peg as the er "type") follow er nurse c down to the er.
upon getting there, there's talk at the nurses station (or whatever u call it in the er) that the pt might not make it in. i sorta felt like a jerk for being disappointed. i wasnt disappointed bc he died. or because i missed an opportunity to help save his lfie. theres nothing wrong with that. no, was disappointed bc i wouldnt get to do cpr and the code n stuff.
so we hang out for a while. saw how everyone gets ready for the code. how they position stuff in the big room to makee space. how RTs are on standby with their bags and machines and stuff. how the ekg tech and whoever else are on standy with their machines and stuff. how the nurses are on standyb with their different roles: how the one nurse is in communication with the medics, how the recorder nurse is ready with her papers and clipboard, how the med nurse and whatever other nurses are hanging out in the area where they would soon do most of there work.
how nurse c had these two cases of emergency meds ready on top of a....was it a bed it was on top of? i dont remember. (nurse c had me and the classmate open the plastic breakaway things keeping the cases shut by twisting them). one case was just like multiple compartments of epi, atropine, both prefilled in syringes built for emergency administration it seems. also there was bicarb, glucose, and some iv bags, the contents of which i didnt ever know. the other case had stuff that was in vials. the only comaprtment i rember for sure was amiodirone (sp?), because we used it.
nurse c's role was to prepare the meds that are called out and hand em to whoever. i think it was nurses actually doing the administering. nurse c was cool. she let me fumble with withdrawing the amiodarone into the syringe. she gave the classmate an opportunity to do prepare a quickdraw atropine or epi or whatevr. she took time to explain stuff and let us try stuff. she was even pretty proactive about getting me in there to do cpr. :)
in all, the drugs we used throughout the code:
*epi
*atropine
saw first hand (multiple times!!) how atropine and epi could take a pt from a 20 or 40 pulse to 120 within seconds! did similar things for bp. dont remember how low it got, but i 220/160 sounds about rt for the highs.
*bicarb (na bicarobate? i dont remember)
will have to read up why was used. but when doc called for it, it was usually around the time he wanted atropine. didnt always call for them together, but when he wanted bicarb, he wanted atropine. always insisted on bicarb b4 atropine.
*heparin.
"5000 bolus." we used it bc doc suspected ischemic MI.
*amiadrione.
used it once. im vaguely familiar with it. know its a heart med. wanna say its for arrhythmias.
-a rectal aspirin (or something). which was weird. the guy shit his pants. not sure if it was b4 or after.
finally i hear someone announce they're here outside. not long after 4 or 5 firefight paramedics come in with a fat guy covered with tubes on top of a stretcher. he kind of stays to the back rattling off the history. there was a lot of confusion and unknowns about this pt xcept this 60 yo male has a history of seizures, and prior to 911 he told his wife he had chest pain, clutched his chest, started seizing, then stopped breathing. (i think). meanwhile there was a lot of impressive teamwork going on, everyone playing out different roles, calling out this and that. everyone was playing independently, and it all worked out and had an organized feel to it. if i didnt know any better, i wouldve guessed it was all orchestrated and rehearsed. it was like an antfarm or something.
meh im getting tired of writing and spending too much time on this. so just bunch of unorganized, barebones bulletpoints now.
-nurse putting in foley set up sterile field n stuff. but didnt come close to maintaining sterility. classmate told me to watch. wonder if she knew nurse's field was contaminated in 2 places.
-i kick ass at chest compressions. sorry dude, didnt mean to break your ribs or sternum or watever. but compressions were most effective when i rotated in. doc says 2 per second. theres this monitor where you can see chest compression rate/depth/etc. i was pretty steady and had the right depth. broke the chest during my second rotation when the compressions werent as deep as they had been during my first set. see it was a big guy who had big lungs i guess, so the doc wanted the compressions deep. i think it was kinda my hand placement the second time. during my first set, i kinda didnt want to stop. i could see that i was more effective than everyone else doing compressions. but i was afraid i would get tired and lose effectiveness during future sets, so i agreed to let others rotate in after i felt kinda tired. i was winded, sweating, and started to feel my triceps burning. rt teacher dood handed me a towel. lol.
-there sure were a lot of ups/downs when it came to vitals. theyd give drugs to boost em up, then they'd drop back down.
-pts blood glucose was like almost 300 but doc said no insulin, wanted pt to keep blood glucose as high as possible. asked nurse c, she said it was to give the guy extra sugar for his brain n stuff.
-there was talk several times questioning the quality of life this guy would have if he made it. early on there was lots of pessimism about his chances. i'm glad they didnt give up. ironically, i am pessimistic about his chances travelling by ambulance to wherever it is they transferred him to. we had to do a lot of shit there in the er.
-but pt had to get transferred to a better equipped er. i'm at a pretty small hospital. when i got back to the floor, the sitter for my pt, who is a new grad nurse waiting for her new grad program to start this summer, was surprised anything like this happened in this er. she said she once had to float down there for a week and it was "pretty chill," which is fine for her since she doesnt like dramatic er stuff anywyay. on another side note, listening to her and the dialysis guy (a nurse?) talk, i got to hear their opinions for which local hospitals are good to work for.
-early on nurse c said she dint think it would end well. doc was ready to give up pretty early on. but 2nd doc didnt want to, said he'd feel bad about doing that. when family showed up, they decided to keep goin.
-classmate was amped up on adrenaline well after the scene was over and we were out of the er. surprised me for a couple reasons. one, she said she wants to do er now because of the focus she felt during all this. i can relate to the focus thing btw but i wouldnt of guessed she was like that. i wouldve guessed it would be overwhelming for her. but i was also surprised bc she didnt get the hands on that i did, right there rotating in doing cpr (she kinda just watched from afar, and in fact seemed kind of nervous when she was asked if she wanted to do it, in fact she insisted i go do it...not once but multiple times), yet for me, it was just something new and cool to be part of. not to say, i didnt care if the pt made it...bc i did want him to make it and was glad when his pulse came back after my compressions. i've spent good times in about 4 ers in my time, even been in various "situations," mosly involving 5150, psych, and drugged out pts, but this was my first cpr code and i like it. er wasnt nearly as exciting as i thought itd be except for those few "situations."
-true story: before i decided to return to nursing school, i was going to do rt school instead because i heard its exciting. and thats what i told the rt students there, who were bagging and rotating in with the chest compressions. the one guy offered to let me rotate in for bagging. pts pulse came back tho. wouldnt mind bagging rt student chick.
-the only emotionally arousing part for me was when the family showed up and i saw what mustve been the wife crying right outside the doorway after they shoo'd the nonessential peeps out of the room. actually it was more what i think mustve been the daughter that set me off. i had to look away everytime i saw her crying. (side note: the only time i came close to feeling that way was when i was in the other program following the home hospice nurse when we sat down with the early-20s-something yo daughter of a patient who the hospice nurse believed was on his way out. er daughter experience was much more intense tho).
-one of nurse c's responsibilities was to talk to the family. i asked if she did it bc was a responsibility or just thats the kind of thing that she gravitates to. she said both. but yes, is responsibility.
k, ill just wrap it up cuz im writing like crap now.
will just say my pt on the floor was pretty interesting too. 91 yo who looks 50. his secret is scotch and water almost daily. haha. dialysis. edema. pacemaker. defibrillator. cataracts returning after lasiks. interesting skins. low ass bp. like 70/50, but denies dizziness. hx crf, pna, hyperlipidemia, diverticulosis, and a bunch of stuff. if i had time to learn all his issues, tx, and meds, i'd learn alot. too bad i dont.
cool clinical day.
Tuesday, June 1, 2010
clinical 6/1/10
random observation. dont feel like elaborating. or writing clearly. ill just cross my fingers and hope i understand what it all means if i ever look over these notes again.
1. around here, u dont get xtra pay for being fluent in a 2nd language. in fact, it's almost expected. weird. must be a wage theory 101 oversupply thing. ie, enought potential applicants with this ability (or few enough positions available), that a premium doesn't have to be paid. im interested in learning a bunch of extra languages, but only at the most non-intesive, non-rushed pace. a financial incentve would prbly be just the thing to push me to take it from an on-off hobby into striving for fluency. oh well.
2. intermittent pain for medical pts. if its not getting progressively worse, sometimes all u can do is wait and see.
3. 2/3 of pts i worked with today were RNs orfamily members of pts here today.
4. observed the whole pre-op checklist thing. wonder why i never witnessed this after a whole semester of medsurg1 at the other program even though i was 1. at a much larger hospital and 2. got to watch actual procedures. we were even taught this checklist pre-procedure thing during the fundamentals class here....but never once at the other program even after a handful of clinicals class.
1. around here, u dont get xtra pay for being fluent in a 2nd language. in fact, it's almost expected. weird. must be a wage theory 101 oversupply thing. ie, enought potential applicants with this ability (or few enough positions available), that a premium doesn't have to be paid. im interested in learning a bunch of extra languages, but only at the most non-intesive, non-rushed pace. a financial incentve would prbly be just the thing to push me to take it from an on-off hobby into striving for fluency. oh well.
2. intermittent pain for medical pts. if its not getting progressively worse, sometimes all u can do is wait and see.
3. 2/3 of pts i worked with today were RNs orfamily members of pts here today.
4. observed the whole pre-op checklist thing. wonder why i never witnessed this after a whole semester of medsurg1 at the other program even though i was 1. at a much larger hospital and 2. got to watch actual procedures. we were even taught this checklist pre-procedure thing during the fundamentals class here....but never once at the other program even after a handful of clinicals class.
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