Tuesday, December 23, 2008
Christmas Eve Eve
So here it is...Christmas Eve eve and what am I doing? I am at work...really I am. I have so much stuff to do, but it will all get done. No need to stress over it. Christmas Eve mass tomorrow...4 pm St Joe's church...finish wrapping Christmas Presents....work tomorrow. Then I am off until the 30th. Then...I am finally on my own, but...I will be at LVH-Muhlenburg...so that is good. Anyway, not much else to say. Hopefully will have some pictures from when we are all together for the holidays. Until then.. Peace love and Happy meals!
Tuesday, December 16, 2008
Dec 16 2008
What have I learned so far this week...yes, I know it's only Tuesday...
I have learned that if you talk smack, you better be able to back it up. I learned that being flexible is ever present in nursing. I learned that being part of a team doesn't always mean your name will be known. I also learned that I love nursing, I just also know that being by the bedside everyday between now and when I can retire already sounds old to me. I learned that bigger hospitals aren't always the best, and that no 2 ICUs are the same.
I have learned that if you talk smack, you better be able to back it up. I learned that being flexible is ever present in nursing. I learned that being part of a team doesn't always mean your name will be known. I also learned that I love nursing, I just also know that being by the bedside everyday between now and when I can retire already sounds old to me. I learned that bigger hospitals aren't always the best, and that no 2 ICUs are the same.
Friday, December 12, 2008
New revelations in the world of Nursing
Ok, so I am now officially halfway through orientation. I am now taking 2 patients, although that is not new for me. What is new is trying to balance the 2 patients AND the crazy charting system. I do however, have 2 new tips for this week. 1- I learned to always tell the crazy computer that I infused the bag of medication before I start the second bag otherwise that next bag gets lost in the world wide web somewhere and I am not exactly sure why it needs cardene. I also learned that you can use a nasal trumpet
as a rectal tube. This was the first time I did and and once I made sure it was leak proof...it actually does work.
as a rectal tube. This was the first time I did and and once I made sure it was leak proof...it actually does work.Not much else going on, yesterday was my birthday which didn't really feel like a birthday at all. I guess that happens as we get older. Joe has been working for a week now at Crayola...and while it isn't his dream job, it is a job none the less. Hope everyone had a great week. Look for another post next week. Until then....
Friday, December 5, 2008
Medical Condition #1
So...
Since I don't really have anything cool to write about...I have decided that I am going to post medical diagnosis of the week. Out of all the days I work, I will pick one diagnosis that I think is the most interesting and I will post it. Here is this weeks...
HHNK
Nonketotic Hyperosmolar Coma
Pathophysiology
Most often an initial presentation of NIDDM or in patients with mild NIDDM
Usually seen in elderly population with underlying chronic disease, esp. CV or renal
2/3 without previous history DM
Often precipitated by infection, MI, CVA
Mechanism unknown-Hyperglycemia occurs, but ketoacidosis does not, allowing more severe hyperglycemia, extracellular and intracellular dehydration than in DKA - hyperosmolality results causing mental status changes
Mortality: 20-60%
Diagnosis
Coma or altered mental status - usually cause for evaluation
Profound dehydration, tachycardia, hypotension
Focal neurologic signs (hemiparesis, hemisensory loss, focal sz) not uncommon
Polydipsia, polyuria, polyphagia - may not be known, or overlooked
Visual complaints
Tachypnea , fever possible
Smell of acetone on breath absent
High suspicion in NIDDM, nursing home pt as condition develops slowly (days-weeks)
Labs
Hyperglycemia-glucose > 800 mg/dL [44 mmol/L], usually >= 1,000 mg/dL [55 mmol/L], check serum glucose
No ketoacidosis
Serum osmolarity > 350
Glycosuria
Serum lytes - Na+ & K+
BUN/Cr
ABG (usually without acidosis)
CBC/UA/CXR to R/O infection
ECG to R/O MI
DDx
DKA
Dehydration
CVA
Precipitants include: MI, CVA, GI bleed, infections, pancreatitis, uremia/CRF, subdural hematoma, peripheral vascular occlusion
Treatment/Disposition
O2, monitor
IVF 0.9NS rapidly (1.5L over 1-2hrs) to stabilize BP & keep U/O >50cc/hr; use 0.45% NaCl if HTN or hypernatremia >155mEq/L [>155 mmol/L]; add 20-40mEq KCL/L as soon as adeq. renal fxn. confirmed
Replace 1/2 of estimated TBW deficit during first 12 hours, the rest during the next 24 hours (too rapid correction may cause cerebral edema)
Average deficit is 8-12 liters
Add dextrose to solution when glucose is 250 mg/dL [13.8 mmol/L]
Monitor CVP & I & Os
Reg. insulin 0.1U/kg IVP followed by reg. insulin drip at 0.1U/kg/hr
Insulin requirements less than in DKA
Monitor glucose, lytes, cardiac status, I & Os q.hr d/c insulin when <350 mg/dL [19.3 mmol/L]
Admit to ICU
Consult endocrinologist
Nursing Considerations
Maintain airway and oxygenation
Careful I/O and fluid and electrolyte replacement
Always double check insulin doses in IV bags and syringes w/another nurse
Maintain skin integrity
Provide for pt safety
Provide emotional support to pt/family
Since I don't really have anything cool to write about...I have decided that I am going to post medical diagnosis of the week. Out of all the days I work, I will pick one diagnosis that I think is the most interesting and I will post it. Here is this weeks...
HHNK
Nonketotic Hyperosmolar Coma
Pathophysiology
Most often an initial presentation of NIDDM or in patients with mild NIDDM
Usually seen in elderly population with underlying chronic disease, esp. CV or renal
2/3 without previous history DM
Often precipitated by infection, MI, CVA
Mechanism unknown-Hyperglycemia occurs, but ketoacidosis does not, allowing more severe hyperglycemia, extracellular and intracellular dehydration than in DKA - hyperosmolality results causing mental status changes
Mortality: 20-60%
Diagnosis
Coma or altered mental status - usually cause for evaluation
Profound dehydration, tachycardia, hypotension
Focal neurologic signs (hemiparesis, hemisensory loss, focal sz) not uncommon
Polydipsia, polyuria, polyphagia - may not be known, or overlooked
Visual complaints
Tachypnea , fever possible
Smell of acetone on breath absent
High suspicion in NIDDM, nursing home pt as condition develops slowly (days-weeks)
Labs
Hyperglycemia-glucose > 800 mg/dL [44 mmol/L], usually >= 1,000 mg/dL [55 mmol/L], check serum glucose
No ketoacidosis
Serum osmolarity > 350
Glycosuria
Serum lytes - Na+ & K+
BUN/Cr
ABG (usually without acidosis)
CBC/UA/CXR to R/O infection
ECG to R/O MI
DDx
DKA
Dehydration
CVA
Precipitants include: MI, CVA, GI bleed, infections, pancreatitis, uremia/CRF, subdural hematoma, peripheral vascular occlusion
Treatment/Disposition
O2, monitor
IVF 0.9NS rapidly (1.5L over 1-2hrs) to stabilize BP & keep U/O >50cc/hr; use 0.45% NaCl if HTN or hypernatremia >155mEq/L [>155 mmol/L]; add 20-40mEq KCL/L as soon as adeq. renal fxn. confirmed
Replace 1/2 of estimated TBW deficit during first 12 hours, the rest during the next 24 hours (too rapid correction may cause cerebral edema)
Average deficit is 8-12 liters
Add dextrose to solution when glucose is 250 mg/dL [13.8 mmol/L]
Monitor CVP & I & Os
Reg. insulin 0.1U/kg IVP followed by reg. insulin drip at 0.1U/kg/hr
Insulin requirements less than in DKA
Monitor glucose, lytes, cardiac status, I & Os q.hr d/c insulin when <350 mg/dL [19.3 mmol/L]
Admit to ICU
Consult endocrinologist
Nursing Considerations
Maintain airway and oxygenation
Careful I/O and fluid and electrolyte replacement
Always double check insulin doses in IV bags and syringes w/another nurse
Maintain skin integrity
Provide for pt safety
Provide emotional support to pt/family
Tuesday, December 2, 2008
It's Beginning to Look a lot like...
...I am working again!! Yay!! I am sitting here at work enjoying some downtime and thought I would post a blog. I love working! Do you have any idea how excited I am to be working again. Oh how I have missed this. I know that I have some wrinkles to work back out again, but man oh man how much I have missed this. I am the lone provider for one patient today, I told my preceptor I wanted to ease slowly back into this, and outside of figuring out the charting I believe I am doing an ok job. Instead of me doing what the minimums are here, I am going to keep myself doing things the Banner way. Not necessarily that that is the "best" way, but it was the way I was taught and I don't want to get lazy. I want to be the best I can be.
I am also going to be going back to school. Something else that I am stoked about! I can't wait to start. Well that is all for now...just wanted to let everyone know that I am in full swing with this working thing...and LOVING EVERY MINUTE!!!
I am also going to be going back to school. Something else that I am stoked about! I can't wait to start. Well that is all for now...just wanted to let everyone know that I am in full swing with this working thing...and LOVING EVERY MINUTE!!!
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