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Starting Out: A New RN in the MICU

Starting Out: A New RN in the MICU

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Published by Mark Hammerschmidt

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Published by: Mark Hammerschmidt on Aug 13, 2008
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09/06/2012

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Starting Out: A New RN In the MICU, from
Mark Hammerschmidt, RN
1-What kinds of patients come into the MICU?2-How do families interact with the MICU staff?3-Who are the nursing staff in the MICU?3-1- Who are the resource nurses?3-2- Who is the nurse manager of the MICU?3-3- Who is the Clinical Nurse Specialist?3-4- How are the assignments made?3-5- Who are the CCTs?3-6- Who are the OAs?3-7- Who are the USAs?4-Who are the doctors in the MICU?4-1- How are the physican teams organized?5-What does Respiratory Therapy do in the MICU?6-Who are the other staff in the unit?7-What are the routines that we use in the MICU?7-1- How do I manage my time during my shift?7-2- How do I use the flow sheet to organize my time?7-3- How should I give report?8-What do I need to know about the monitors?8-1- Should I believe everything the monitors tell me?8-2- What can the monitor do?8-3- How does the information get from the patient into the monitor?8-4- How should I react to the alarms?9-What are the different pumps used for in the unit?9-1- What are microinfusion pumps?10- What are all the lines going into these patients?10-1- How does the line connect the patient to the monitor?10-2- What are the inflated white bags for, that hang on the poles in the rooms?10-3- Why do they use that stiff tubing for the transducers?10-4- What should I worry about when using these lines?10-5- How should I organize the lines?11-What kinds of labs do we send on the ICU patients?11-1- What do I do with the results?
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12-What is the procedure for admitting a patient to the ICU?12-1- Admitting from the OR?12-2- What are “boarders”?13-What do I need to know about giving meds in the ICU?13-1- What are pressors?13-2- What other drips do we use?13-3- How do I make sure that I’m doing all this correctly?14-What are some of the tests that the patients may have done here in theunit itself?15-What tests do patients travel out of the unit for?15-1- How do I take a patient to CT scan?15-2- What do I do when I’m at the scanner?15-3- What other scans do patients travel for?16-What do I need to know about IV access?16-1- Peripherals.16-1-1- Where should they go?16-2- Central lines.16-2-2- Where should they go?16-3- Should I put in my own peripheral lines?16-4- What do ICU nurses give through IVs in the unit?16-4-1- Crystalloid.16-4-2- Blood products.16-5- IV meds.17-What are some of the common emergency situations that come up in the MICU?17-1- Some basic thoughts about emergencies.17-2- Cardiac/hemodynamic situations.17.2.1- Hypotension.17.2.2-Arrhythmias17-2-3- Not-so-scary arrhythmias.17-2-4- “Flashing”. (No, not that kind!)17-2-5- Codes.17-3- Respiratory situations.17-4- ID issues.17-5- Renal failure.17-5-1- Urology problems.17-6- GI situations.17-6-1- GI bleeds.17-6-2- Liver failure.17-7- Neurological situations.17-7-1- What should I worry about?17-7-2- Bolts.17-7-3- A zebra…17-8- Psychiatric situations.17-8-1- Overdoses.
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18- How do I deal with my own stress in the unit?18-1- Being scared.18-2- Feeling stupid.18-3- What do I do if I make a mistake?18-4- What if I find someone else’s mistake?18-5- What do I do if I think the doctors are telling me to do the wrong thing?18-6- What if I think the doctors aren’t listening to me?18-7- How should I go up the chain of command if the doctors aren’t listening to me?18-8- How should I involve the resource nurse?18-9- What do I do if I think that the patient treatment is unethical?19- A word about levity…To start with…In thinking about how to organize this FAQ, it certainly seemed that there was a whole lot of material to cover – where would you start? Obviously from somewhere... a little later, I realizedthat a good way to put things together would be to describe them in the same way that we giveshift report – in the same way that we try to cover all the bases when we do that, starting withage, gender, history, where admitted from, and then a system-by-system review of the patient,ending up hopefully with a coherent picture of the current situation. So I thought that this might bea useful way to break up a description of the ICU: into manageable chunks that, while they couldbe described separately, should add up to a whole system for treating whatever comes in thedoor. Let me know what you think! Please remember that this material is in no way ‘official’ – it ismeant to represent information as it would be passed from a preceptor to a new ICU nurse. Asusual, mistakes – and there will be plenty of them – are mine. Please let me know when you findthem, and I’ll work the answers in and update the file. Thanks!To start with – here’s a scenario that I remember all too well. It was a little extreme, but it’s a truestory, and it helps illustrate a lot of what makes working in the ICU so different: (lots of the detailshave been changed to protect identities).A patient comes in as a transfer from another hospital. He’d been brought down from somewherein New Hampshire, where he’d been eating home-cured meats and apparently drinking home-made liquor. He’d gotten a stomachache, so he took “a handful” of aspirin. When this didn’t help,he apparently repeated the dose. Probably a bad idea –he developed an enormous lower GIbleed, became hypotensive, and by the time he finally got to us, he’d infarcted much of his bowel,knocked off his kidneys, gone into shock liver, and when I first saw him he was postop, havinghad a large segment of his bowel removed. He’d required so much fluid peri-operatively that thesurgeons had been unable to close him – instead, his abdominal wound was open, covered witha clear, adherent OR drape, and he had normal saline infusing into the wound continuously fromseveral IV pumps for irrigation. The wound was being drained by several salem sumps laid intoand across the incision. He was in ARDS, so he was vented, sedated, and chemically paralyzed.He was extremely septic, hypotensive, and he was on at least two pressors. He was on TPN. Tocorrect his renal failure he had been started on CVVH (bedside dialysis). I’ll put each part of thereport that I might give in quotes, and I’ll try putting the topic being discussed into some kind of dialogue: “Holy cow, this guy is in tough shape.”
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