Before Receiving the PatientEdit
As soon as I find out the name of my new open heart patient, I review his records to learn as much about him as I can before he arrives from the OR. When receiving a patient post open heart surgery into the ICU, there can be a daunting display of high tech equipment, lines, tubes, beeping monitors and a tangle of lines -- and underneath it all one can find the patient. It is important to pay immediate attention to the patient -- but to not forget to carefully check over all the pieces of equipment very soon. Ideally the nurse will have a helper who can tend to the equipment, but this is not always possible.
The members of the team that escorts the patient to the ICU room usually help connect various monitors to the patient's body. This is the time when the nurse glances at the patient while listening to a brief report from the anesthesiologist.
- What medications were necessary to keep the patient stable throughout the surgery
- What medications are currently being given,
- How much fluid has the patient received,
- What is the ejection fraction,
- What were the results of the last set of blood gases, blood counts and electrolytes
These are the important pieces of information the nurse needs to take over the care of the patient. Before long, everyone is gone, and the nurse is alone with the patient, observing his recovery from major surgery.
It is imperative to note the amount of blood in the chest tube drainage chamber and the amount of urine in the Foley bag right away in order to assess continued values. If the blood pressure and pulse are acceptable, you can now go to work on the patient. From my perspective, I leave the respiratory status of the patient to the respiratory technician who is at this time connecting the patient to the ventilator and adjusting the settings to obtain optimal ventilation.
Is the patient awake? Perhaps he is already stirring -- and this is not the time for him to wake up. I prefer a controlled awakening, and if the patient is waking, I will give a small amount of Fentanyl and/or midazolam. This provides a bit more sedation and pain control at this time.
I touch the patient's skin...head, arms, trunk, legs, feet. If he has warm feet, I am happy, because WARM FEET WITH WELL FELT PEDAL PULSES are well perfused feet. The Foley catheter's temperature probe is connected to the monitor and displays the temperature. If it is less than C 36.0, I will place a Bair Hugger or other warming device. Otherwise I just place a warm blanket over the patient's body. I prefer two blankets: one to cover the upper half of the body and one to cover the lower half -- allowing the chest tubes to exit from the body on top of the lower half of blankets. This way I can see the chest tubes all the time without having to uncover the patient, keeping him warm and also not constantly bothering him.
What is the heart doing -- this pump that was cut and sewn upon, stopped from beating, cooled and flooded with solutions only a short while ago? I look at the monitor to observe for irregular beats. Does the heart beat sound sturdy? If there was an artificial valve placed, does it sound crisp? Are peripheral pulses palpable? Do the fingers blanch on pinching and does the blood return quickly? If an external pacemaker is pacing the heart, I now check the values and the power necessary for capture. I place the pacemaker box in a very secure position, usually hanging on a hook at the head of the bed. If the skin is warm and dry, and if the pressures and the rate are in a good range, I move on.
The ventilator is taking care of gas exchange for the patient. I listen to the lung fields to be sure air is getting to all areas of the lung. I will check an arterial blood gas soon to assess the effectiveness of ventilation. I look at the chest: are the tubes secured, are the pacer wires accessible if they are not connected? Is the drainage from the chest tubes pulsating(blood column moving)? Is it clotting? Is the dressing over the incision dry?
I glance at the abdomen. There won't be any bowel tones to note at this time, but I make a mental note to consider placing an oro gastric tube later if one is not already placed. Some patients benefit from decompression of air in their stomach. I feel the form of the abdomen and let my hands wander down further to the groins of the patient. Are there lines inserted? Femoral arterial line? Is it secure and clean?
Is the Foley catheter draining properly? What is the amount and nature of the urine?
Once again I feel the feet. This completes a basic head to toe examination of the patient, and if the findings are in the range of the expected, I next move to examine the equipment.
Again, a glance at the chest tubes to determine the rate of blood drainage, and I move on to assess the proper functioning of lines and pumps.
- Pressure line transducers need to be placed at the correct level for the numbers they generate to be accurate. I always check a manual blood pressure to compare with the art line. If the MAP is close, I am satisfied that the results I get are valid, and I now continue to just monitor the art line, I assess the wave forms, zero, flush, assess the pressure bags and adjust the alarms that will sound for the upper and lower limits of values generated by the measuring equipment appropriate for this patient.
- I glance at the medication infusing. I follow each infusion drip from the bag to the pump and to the central line in the patient's neck. I label the medication tubing to avoid errors. I review the rate of infusions. I continue to observe the patient and the monitor while I untangle lines and arrange the equipment so that it is out of the way of the patient, in a safe position and easy to assess.
- I tape the exposed pacing wires so that they can be accessed easily if needed.
If no complications arise, I now sit down next to the patient's bed, and I begin to fill in the flow sheet. I chart the time the patient arrived, keep track of hemodynamic readings every 15 minutes. I keep track of which medications infuse at what rates, and of how much drains from the patient's chest and how much urine is produced. When I am satisfied that the patient is stable for the time being and that the flow chart reflects current readings, I have finished receiving the patient.