News about nursing, test taking, and interesting finds.

What Should I Bring on the First Day of Nursing Clinicals?

Don’t be like me.  A long time ago in an ICU far, far away I showed up for my first day of work with a cable-guy sized storage clipboard and a 5-pound double-belled stethoscope slung over my neck.  I whipped out my brick-sized PDA and licked my stylus (I know) just as I looked around and realized how cool I wasn’t.

overwhelmed

Have you seen my stylus?

Choosing the right tactical equipment for your first day of nursing is a little overwhelming.  I know that I was sweating like a gypsy with a mortgage the night before, stuffing my clipboard with unneeded items.  In America’s online economy of instant gratification, some people wind up with “paralysis by analysis”.  This is when you become deluged with consumer choices.  Throw in a little paranoia about your first day at the hospital and you’ve got a recipe for an overdrawn Amazon account.

Let’s talk about the actual tools necessary to get the job done efficiently, intelligently, and comfortably.  Coming prepared is essential as nurses can quickly become swamped with screeching call lights and overdue order sets.  There are certain pieces of equipment necessary to get the job done, so let’s review a list of things to consider bringing on your first day!

  • The right pen

This is an area of deep obsession and constant modification.  One’s pen is a tool of the trade and a weapon in the arsenal of nursing that is so personal I hesitate to give advice.  I look for retractable, fine point, black pens that are reliable.  Given that this device will be used constantly throughout your shift, affordability takes a backseat.  I recommend the Pilot G2 Retractable Gel Roller Extra Fine Point 0.38mm in black.  This bad boy makes its mark every time, fits into the tiniest of vital sign boxes, and won’t leak on your scrubs.  Make sure you always have backups and order at least 5 at a time.  Or take your chances and lend it to someone, “For just a second, maaaan.”

  • Stethoscopes

This piece of equipment is like a calling card around your neck.  It is the most visible piece of equipment you will own and introduces your level of proficiency before you even open your mouth.  If you’re like me, and you show up with a 5-pound Fisher Price monstrosity, savvy clinicians will notice.  Don’t go crazy and purchase the Littmann Cardiac III right out of the gate ($300).  Start with something manageable and affordable.  I suggest the 3M Littmann Lightweight II S.E.  At first, my only criteria was if the scope was long enough to reach the patient.  Upon further investigation, I approached my next stethoscope with 3 criteria in mind. 1. Value:  This scope is pretty much the same quality as the Classic at a lesser price. 2. Weight: A few ounces can make all the difference, especially over a long shift.  Avoid the anchor-like scopes if you can.  3. Sound: If you want to be able to detect lung, bowel, and S1/S2 heart sounds when the unit clerk is telling her favorite knock-knock joke or the dementia patient is screaming from across the hall, then get this one.  It’s an all-around beast and you won’t freak out if it grows legs and walks (see: taken by an unscrupulous co-worker).

Boy, I wish these were more ubiquitous when I started nursing.  As I mentioned, my PDA with complimentary stylus was super-lame even in my day.  Don’t be that guy.  There are a several apps out there for the resourceful nurses of today.  In the interest of full-disclosure, I’m going to plug two projects that I have created.

Nurse Notes is a powerful iTunes app that sends you audible & visual reminders about patient care and scheduled tasks during your shift.  Since the app also stores data and acts as a “brain sheet”, it helps you chart & assists during report.  With this app you can avoid writing everything down by easily programming the app at the start of your shift.  Take a few minutes at the beginning of your shift to plugin essential, patient specific reminders or simply and quickly select from dozens of distinct choices within the main drop-down lists.

Homepage Nursenotes

75 Nurse Cheat Sheets is a portable eBook instantly accessible on your mobile phone and is one of the largest collections of nursing labs, medications, assessments, procedures, acronyms, diagrams, mnemonics, equations, conversions, scales, graphs, pictures, medical abbreviations, and Spanish translations. This enormous reference can replace all of the expensive and bulky laminated clinical sheets that most nurses mistakenly buy for $5 a pop.  It also includes detailed tables, diagrams, algorithms, and charting tools.

LungvolumesOvsR

Lungvolumedescriptions

 

  • Hemostats & Shears
multitool

Reflex hammer and amputation multitool awaiting patent.

Good news.  Hemostats are cheap so you should get whatever’s affordable.  A $2 Kelly will grip just as well as the $20 surgical version.  It might wear out a bit faster, but does it matter?  Long before it breaks it will only get lost, stolen, or accidentally dropped into the sharps box anyway.  Hemostats can be used to unscrew a luer lock that is coagulated with smegma or stop an artery from bleeding at the scene of an accident by the side of the road.  Versatile and worth having around!  I recommend Kelly Forceps.

As for shears, quality is a little more important.  The cheap ones will bend if you try to cut anything tough, like leather.  Still, a good pair can be had for less than $10.  I suggest a set of Prestige Medical Fluoride Scissors.  Extra points if you buy the black ones and look like a rogue EMT!

  • Compression stockings vs. Sweat wicking athletic socks

The debate rages on.  Not really.  This one comes down to personal preference, or biology.  If you’re like me, you’re double screwed.  My parents have varicose veins, which I’m doomed to inherit, and my wife says my feet stink.  I’m partial to sweat wicking athletic socks as a person who is obsessively self-conscious about my hygiene.  In fact, I tried wearing compression stockings but with my hairy man legs and sensitive follicles (I can’t wear hats either for this reason) the stockings practically gave me dermatitis and claustrophobia at the same time.  You will be on your feet for brutally-long periods of time, so if compression stockings help your circulation then go for it.  But if you’re gonna wear them, do it in style without looking like an old diabetic lady feeding birds at the park with these Nabee Socks.   I prefer the Drymax sport sock, though.  They wont’ save your feet from a foley spill but they’ll help reduce the sweat, prevent fungus, and cut down on blisters.

  • Snacks

Do your part… Prevent hypoglycemia in nurses.  Really, though.  I’ve gotten so hungry you could hear my stomach during report.  It’s important to fuel up whenever you can as a busy nurse.  Most units don’t allow food but I’m gonna suggest some ninja workarounds.  I like to stash low-glycemic index foods, high in fiber, that won’t make me thirsty, or make my breath reek when I’m going in for breath sounds on my patient.  I prefer plain almonds and, my guilty pleasure, 5-Hour Energy.  There are those times when you just need a pick-me-up and coffee won’t do.  Just be careful not to take it in anticipation of being tired or you’ll be pacing around the unit like a coked-out patient from the ER trying to convince people to fund your new KickStarter campaign.

  • Fanny packs

No.

  • Sharpies!

Yes.  The need for sharpies will always endure.  Make your mark with a nice fine-tipped Sharpie permanent marker.  Get the multi-pack with clips for convenience and visual variety.  You can date your IV bag, label your lines, or scrawl a love letter to that nurse you fancy in the neuro unit.  I go with the Mini Sharpies because I’ve got enough junk in my pockets and these babies, much like hemostats or pens, will get lost or stolen before actually drying out.

  • 2 week’s worth of scrubs (6 sets)

Layered and worn all at the same time for that androgynous yet buff look.  Actually, you’ll thank me when you’re butt is dragging out of bed for your last of 3 shifts of the week and you’ve got a nice clean pair waiting for you.  The last thing you want to do after a long shift is go home and do laundry for your next shift.  Have 3 pair for each week and alternate!  I recommend… whatever you want.  My only real suggestion is that you have plenty of them.

  • Vick’s or tincture of peppermint
oops

Yes, yes you did. Hand me the Vick’s.

On my first day at the hospital I couldn’t have ventured a guess as to what this would be used for.  You’re first code brown, though, will reveal the necessity of this odor-squashing lifesaver.  The smell of poo can be tougher than woodpecker lips to eliminate.  So why not just cover it up until you clean it up?  Spread a little of either of these potions on the outside of a preformed mask then layer another mask on top of that.  You’ll be whistling dixie and hot-trotting around the room oblivious to the wretched stench.

This is far from a comprehensive list, but you get the idea.  A nurse is always refining their tool box.  For instance, I won’t even touch on the lifelong odyssey of finding the right pair of shoes.  It takes a while to get into your groove and get comfortable with the tools of the trade.  Everything about a nurse’s practice continues to evolve so keep your eyes open, learn from your mistakes, and don’t buy that fanny pack.

 

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Sepsis Nursing Treatment & Medications

Septicemia

 

Septicemia is a systemic inflammatory response to an infection that causes circulatory dysfunction.  When infections become blood borne and spread throughout the body, capillaries become more permeable, hypotension occurs, coagulation increases, and immune mediators are released. Infections leading to sepsis are usually bacterial but can also be fungal or viral. The term sepsis is often used interchangeable with septicemia and refers to a bloodstream infection. Sepsis can occur with or without organ dysfunction, depending on severity. Sepsis can be further classified as follows:

  • Systemic Inflammatory Response (SIRS): Infection in conjunction with the systemic inflammatory response syndrome.
    • Temperature > 38 C
    • Heart rate > 90 bpm
    • Respiratory rate > 20 bpm
    • WBC > 12,000/mm3
  • Severe Sepsis: Sepsis complicated by organ dysfunction.
  • Septic Shock: Sepsis causing acute circulatory collapse resulting in refractory hypotension unrelieved by intravenous volume resuscitation.

Sepsis is typically associated with a causative condition primarily from the skin, abdomen, lungs, or urinary tract, such as bowel perforation, pneumonia, pyelonephritis, renal abscess, or urosepsis related to a urinary tract obstruction.

CAUSES & PREVELANCE

Sepsis, or septic shock, is associated with direct introduction of pathogenic microorganisms. The most common iatrogenic sources are central or peripheral venous catheters, catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), and ventilator-associated pneumonia (VAP). Despite only accounting for 2% of hospitalizations in 2008, sepsis caused 17% of all in-hospital deaths. In a hospital setting, 50% of all sepsis cases start as an infection in the lungs. No definitive source is found in 1/3 to ½ of all documented cases.

The rate of hospitalization for septicemia has more than doubled since 2000. The sharp rise in cases has been attributed to microbial resistance due to increased use of antibiotics, greater use of invasive procedures, an aging population with more chronic illnesses, immunosuppressive drugs, chemotherapy, transplantation, increasing microbial resistance to antibiotics, and greater awareness of sepsis resulting in more frequent and accurate medical diagnosis and coding.

PATHOPHYSIOLOGY

The pathophysiology of sepsis is complex and related to the pathogen and its virulence and the patient’s immune status. Sepsis is characterized by a systemic inflammatory response resulting in systemic vasodilatation, hypotension, increased cardiac output and eventual end-organ damage caused by limited oxygen extraction by the tissues. The primary effects come from endogenous cytokine release (i.e. tumor necrosis factor, interleukins) and the inflammatory cascade in response to circulating bacterial products. Impaired pulmonary, hepatic, or renal function may result from excessive cytokine release. Disordered coagulation results in activation of the clotting cascade and a reduction in the natural inhibitors of clotting, such as activated protein C. Once initiated, the process is self-perpetuating without regard to the initial infection. Microcirculatory blood flow is impeded by an increase in thrombosis formation and reduced fibrinolysis (clot breakdown), microcirculatory ischemia, and eventual multiple organ dysfunction (MODS).

The stages of sepsis can be divided as follows:

  • Infectious insult
  • Initial systemic response
  • Overwhelming systemic response
  • Anti-inflammatory reaction
  • Immunomodulatory failure

EPIDEMIOLOGY & PROGNOSIS

Septicemia can quickly become life threatening if not recognized early and treated aggressively. Patients hospitalized for septicemia have twice the average length of stay versus patients hospitalized for other conditions and are eight times more likely to die during their hospitalization. Approximately 30-70% of patients with septic shock die. Patients who survive severe sepsis are more likely to have permanent organ damage including cognitive impairment and physical disability.

Several prognostic assessments exist to stratify sepsis outcomes. Lactate levels have been shown to be directly proportional mortality rate. The APACHE II scale can help classify the severity of the disease by calculating a score based on physiological measurements including: arterial pH, potassium, creatinine, hematocrit, and Glasgow coma scale. Without progression to septic shock, approximately 20-35% of patients still do not survive.

SIGNS & SYMPTOMS

bacterial_infections

Taking an accurate patient history is important in determining the potential source of sepsis. This will help guide essential antimicrobial therapy. Due to the vague nature and systemic progression of sepsis, it is difficult to determine the source without reviewing all systems and performing a thorough physical assessment. Most signs and symptoms relate to hypotension, coagulopathy, infection, and hypoperfusion of organs. The following are general signs and symptoms and special considerations:

  • Fever > 38 C or < 36 C
  • HR > 90 bpm
  • RR > 20 bpm
  • WBC > 12,000/mm3
  • Shaking or chills
  • Altered mental status
  • Oliguria: < 0.5 mL/kg/hour
  • Warm skin with dilatation of the superficial vessels
  • Cold skin with inadequacy of organ perfusion

ASSOCIATED CONDITIONS

  • IV line infection:
    • Almost always central line site vs. peripheral or arterial lines
    • Suspect if other potential sources are eliminated and patient has long-term IV line in place
  • Gastrointestinal or genitourinary infections:
    • Ileus: absent bowel sounds
    • History of pyelonephritis, renal abscess acute prostatitis, or prostatic abscess
    • Abdominal pain suggests pancreatitis or peritonitis
    • Right upper quadrant tenderness suggests gallbladder etiology
    • Right lower quadrant tenderness suggests appendicitis or Crohn’s complications
    • Left lower quadrant tenderness suggests diverticulitis
    • Abnormalities on rectal exam like severe tenderness suggest a prostatic abscess
    • Costovertebral angle tenderness suggests pyelonephritis
    • Elderly may have peritonitis without rebound tenderness of the abdomen
  • Urosepsis: Most common cause of sepsis in pregnancy secondary to obstructed urinary tract
  • Burns
  • Asplenia: No spleen
  • Gastrointestinal Disorders:
    • Intestinal obstruction
    • Gallbladder disease
    • Colon disease
    • Abscess
    • Liver disease
    • GI surgery
  • Ethanol abuse
  • Genitourinary Disorders:
    • Renal calculi
    • Pyelonephritis
    • Urinary tract obstruction
    • Acute prostatitis
    • Prostatic abscess
    • Renal insufficiency
    • GU catheters
  • Diabetes mellitus
  • Lung Disorders:
    • Empyema
    • Lower respiratory tract infection
    • Community-acquired pneumonia
    • Lung abscess
  • Immunocompromised
  • Bacterial endocarditis

DIAGNOSTIC STUDIES

  • Lactate: Marker for cellular hypoxia, normal 0.5-2.2 mmol/L, above 4.0 mmol/L = 27% mortality rate
  • Complete blood count: Anemia, elevated or low white blood cell count, or thrombocytopenia
  • Arterial blood gas: metabolic acidosis and arterial hypoxemia (PaO2/FiO2 < 300 mmHg)
  • Blood Glucose: Septic patients can have > 140 mg/dL without diabetes
  • Creatinine: > 0.5 mg/dL
  • Troponin T: > 0.1 ug/L in 85% of sepsis without coronary syndrome
  • Cultures: Blood, IV catheter tip, or urine cultures on admission before starting antibiotics to determine specific microbial target
  • Gram stain blood: Differentiate between gram positive and gram negative organisms
  • Urinalysis: Perform gram stain and culture
  • C-Reactive Protein: identify presence of inflammation and monitor response to treatment
  • Procalcitonin: Evaluate risk of developing system bacterial infection
  • Presepsin: Early risk stratification
  • Clotting screen: D-dimer and fibrinogen will reveal disseminated intravascular coagulation
  • Chest X-ray: Rule out pneumonia
  • Abdominal CT or MRI: Assess for peritonitis, abdominal abscesses, and renal pathology
  • Abdominal Ultrasound: Exam liver, gall bladder, pancreas, and biliary tract for obstruction
  • Thoracentesis: Patients with significant pleural effusions
  • Paracentesis: Patients with ascites
  • Swan-Ganz catheterization: Guides fluid management and reveals left ventricular dysfunction
  • Invasive investigation: Lumbar puncture, bronchoscopy, laparoscopy, lymph node biopsy

NURSE MANAGEMENT

  • ICU admission for monitoring and treatment
  • Lactate: Obtain initial serum level and regular follow-ups
  • Foley insertion: Monitor urine output closely to guide therapy and fluid replacement, goal > 0.5 mL/kg/hour
  • Intravenous antimicrobials: Cultures followed by broad-spectrum antibiotics given intravenously. Antivirals and antifungals may also be required. Once organism is isolated through lab cultures, the regimen may be targeted for the pathogen. Empirical combination therapy should not last longer than 3-6 days. Reducing to single therapy should be done as soon as the pathogen profile is known:
    • IV line infections: Line removal then meropenem or cefepime
    • MRSA: Linezolid, vancomycin, or daptomycin
    • Biliary tract infections: Imipenem, meropenem, piperacillin-tazobactam, or ampicillin-sulbactam
    • Abdominal and pelvic infections: Imipenem, meropenem, piperacillin-tazobactam, ampicillin-sulbactam, or tigecycline; clindamycin or metronidazole plus aztreonam, levofloxacin, or an aminoglycoside
    • Urosepsis: Aztreonam, levofloxacin, a cephalosporin, or an aminoglycoside
    • Enterococci: Ampicillin or vancomycin;
    • Vancomycin-resistant enterococcal urosepsis: Linezolid or daptomycin;
    • Community-acquired urosepsis: Levofloxacin, aztreonam, or an aminoglycoside plus ampicillin
    • Nosocomial urosepsis: Piperacillin, imipenem, or meropenem
    • Pneumococcal sepsis: Cephalosporins, carbapenem, or vancomycin
    • Sepsis of unknown origin: Meropenem, imipenem, piperacillin-tazobactam, or tigecycline; metronidazole plus either levofloxacin, aztreonam, cefepime, or ceftriaxone
  • Fluid Resuscitation:
    • Crystalloid 30 mL/kg: If hypotensive
    • Crystalloid 4-6 Liters total: Often required for septic shock
    • Colloids IV: Osmotic force may counteract third-spacing from increased capillary permeability, used only when unresponsive to isotonic crystalloids
    • Monitor fluid overload: dyspnea, crackles, JVD, pulmonary edema
  • Transfusions:
    • RBC transfusion: If patient’s hemoglobin falls below 7 g/dL
    • Platelet transfusion: Severe sepsis causes thrombocytopenia, transfuse < 20,000
    • FFP, Fibrinogen, or Cryoprecipitate: Consider with DIC, active bleeding, elevated PT, and decreased fibrinogen
  • External cooling: Fever control which may reduce vasopressor requirements
  • Enteral nutrition: Electrolyte and protein deficiencies are common, do not give parenterally, caution ileus
  • Vasopressors:
    • Indicated for hypotension that does not respond to initial fluid resuscitation
    • MAP > 65 mmHg: Administer fluids & vasopressors
    • CVP > 8 mmHg: Monitor central venous pressure to guide fluid resuscitation and vasopressors
    • ScvO2 = 70%: Monitor central venous oxygen saturation for cellular supply and demand
  • Supplemental oxygen: Monitor respiratory effort closely as respiratory failure is a risk
  • Dialysis: Patient may experience kidney failure
  • Monitor blood glucose: Goal < 150 mg/dL
  • DVT prophylaxis: heparin when not contraindicated, SCD’s
  • Asepsis: Maintain strict aseptic technique
  • Mechanical ventilation:
    • Acute Respiratory Distress Syndrome (ARDS) carries very poor prognosis
    • Tidal volume 5-8 mL/kg
    • Elongated inspiratory time
    • Sufficient PEEP
    • Peak pressure < 30 cmH2O

 

MEDICATIONS

– Norepinephrine

  • Trade Name: Levophed
  • Indication: Acute hypotension, sepsis, septic shock
  • Action: Increases blood pressure, cardiac output, and heart rate, beta-1 and alpha-adrenergic effects with moderate beta-2,
  • Class: Alpha/Beta adrenergic agonist
  • Considerations:
    • First line treatment of septic hypoperfusion unresponsive to fluids
    • 2-1.5 ug/kg/min up to 3 ug/kg/min due to alpha down-regulation in sepsis
    • Monitor blood pressure closely
    • Splanchnic (abdominal) perfusion can become compromised from prolonged administration
    • Caution IV site extravasation

– Dopamine

  • Trade Name: Intropin
  • Indication: Hypotension, low cardiac output, hypoperfusion of vital organs, raises mean arterial pressure in septic shock patients after fluid resuscitation has failed
  • Action: Endogenous catecholamine, stimulating dopaminergic and adrenergic receptors
  • Class: Inotropic agent
  • Considerations:
    • Low dose (1-5 mcg/kg/min) produces renal and mesenteric vasodilation
    • Moderate dose (5-15 mcg/kg/min) produces cardiac stimulation and renal vasodilation
    • High dose (20-50 mcg/kg/min) stimulates alpha receptors producing systemic vasoconstriction and increased mean arterial pressure
    • Use with caution in angina due to increased oxygen demand of heart
    • Always fluid resuscitate first
    • Prevent tissue damage at IV site by monitoring for extravasation

– Hydrocortisone

  • Trade Name: SoluCortef
  • Indication: Vasopressor-refractory shock or adrenal insufficiency secondary to cortisol stimulation test, improved survival of ARDS
  • Action: Controls or prevents inflammation by reducing rate of protein synthesis and suppressing migration of polymorphonuclear leukocytes and fibroblasts, reverses capillary permeability
  • Class: Corticosteroid, Glucocorticoid
  • Considerations:
    • High-dose corticosteroids should not be used with sever sepsis
    • Lower-dose (physiologic) steroids are beneficial for patient with adrenal insufficiency
    • Measuring cortisol levels before and 30 minutes after IV administration of ACTH can reveal adrenal insufficiency
    • Majority of patients with vasopressor-refractory sepsis benefit
    • Hydrocortisone 100 mg IV or Dexamethasone 10 mg IV

– Epinephrine

  • Trade Name: Adrenalin
  • Indication: Second-line agent for persistent hypotension despite fluid, norepinephrine, and dopamine administration, can be used in cardiac arrest
  • Action: Mainly alpha-adrenergic stimulation causing systemic vasoconstriction, strong beta-1 and beta-2 resulting in increased cardiac output, heart rate, and bronchial smooth muscle relaxation
  • Class: Alpha & Beta adrenergic agonist
  • Considerations:
    • Tachyarrhythmias and myocardial ischemia can result from strong beta-1 stimulation
    • Rapid increase in blood pressure can cause cerebral hemorrhage
    • May increase lactate and blood glucose levels
    • Gut ischemia from diversion of blood flow, must monitor bowels
    • 1-10 mcg/min IV infusion, titrate to effect

– Vasopressin

  • Trade Name: ADH, Vasostrict
  • Indication: Second-line agent for vasodilatory shock, should be used to supplement concurrent use of norepinephrine
  • Action: Endogenous peptide normally released from posterior pituitary that vasoconstricts without inotropic or chronotropic effects, stimulates peristalsis
  • Class: Antidiuretic hormone analog, Vasopressor
  • Considerations:
    • 03 U/min IV infusion added to norepinephrine as a therapy to treat unresponsiveness and reduce requirements for catecholamines
    • Restores effectiveness of catecholamine first-line agents
    • Increases renal perfusion and stimulates peristalsis

– Insulin

  • Trade Name: Humulin R, Novolin R
  • Indication: Glycemic control and avoidance further inflammatory response
  • Action: Reduces cytokine release, prevents polyneuropathy and myopathy, attenuates inflammation, and can decrease lactate formation
  • Class: Antidiabetic, Insulins
  • Considerations:
    • Previous recommendations were blood glucose levels 80-110 mg/dL but episodes of hypoglycemia negated any potential benefits
    • Recent sepsis-specific recommendations call for maintaining glucose level below 180 mg/dL
    • Administer in drip form according to ICU IV insulin infusion protocol
    • Insulin needs to be on connected to carrier line with fluid to infuse continuously
    • Blood glucose checks usually hourly

– Heparin

  • Trade Name: No trade name
  • Indication: Prevention of DVT or thrombosis-dominant disseminated intravascular coagulation (DIC)
  • Action: Inactivates factor Xa and inhibits conversion of Prothrombin to thrombin, inactivates factors IX, X, XI, and XII, and inhibits activation of factor VIII
  • Class: Anticoagulant
  • Considerations:
    • Only administer in the absence of active bleeding or thrombocytopenia
    • Caution creatinine clearance less than 30 mL/min
    • When contraindicated, use compression stockings or sequential compression devices
    • Also use in presence of inadequate perfusion to extremities or vascular skin infarctions
    • Weight-based dosing starting at 10 U/kg/hr with goal aPTT of 1.5-2.5 longer than patient’s pretreatment level

– Albumin

  • Trade Name: Albuminar, Alba
  • Indication: Hypovolemia and hypotension after substantial amounts of crystalloids have been administered
  • Action: Intravascular volume expansion through mobilization of fluids from interstitial spaces
  • Class: Volume expander
  • Considerations:
    • Increases circulating plasma volume by 3.5 times the volume infused within 15 minutes
    • Hemodilution lowers hematocrit and lowers blood viscosity
    • Monitor for signs of volume overload: dyspnea, JVD, crackles, pulmonary edema
    • Crystalloids should be given in 2-4 times greater quantity first
    • Results should be evident in CVP, PAOP, and urine output

– Phenylephrine

  • Trade Name: Vazculep
  • Indication: Second-line vasopressor for persistent hypotension despite maximal doses of norepinephrine and dopamine
  • Action: Strictly alpha-receptor agonist resulting in increased peripheral vascular resistance and blood pressure at the expense of cardiac output, heart rate and renal perfusion
  • Class: Alpha 1 agonist
  • Considerations:
    • 80-200 mcg/min IV infusion
    • Caution with cerebrovascular insufficiency and cardiovascular disease
    • Consider as first-line agent with tachycardia as it will reduce heart rate quickly and reliably while other catecholamine agents can exacerbate tachycardia
    • Extravasation can cause tissue ischemia
    • Reflex bradycardia should be considered in patients with low heart rates
    • Decrease in cardiac output can be detrimental in patients with hypermetabolic state like sepsis

Starting an IV

Have you ever stared longingly at a sweet pair of pipes rippling the surface of the forearms of gym-rat?  I must confess that, as a nurse, I have practically salivated at the sight of bulging veins on some stranger in the hospital elevator.  It’s second nature for nurses to have their radars attuned to a good intravenous puncture site.  It’s also second nature for experienced nurses to perform the set of operations required to start an IV in under 10 seconds.  Well, what about the rest of us that struggle with such seemingly mundane tasks?  Don’t worry!  I was once a new grad with shaky hands awkwardly approaching an equally nervous patient.  I fumbled over my set-up, searched for supplies, and perspired over my field.  So, if you were like me then this post is for you, my friend.  Keep reading for a simplified, step-by-step guide to starting an IV.

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