Intern Prep Top Calls

1. Intern Prep  Top Calls

3. Starting Internship Crash Course Today�s Goals: Preview/Practice your response to the most common nursing calls. What you might say/request over the phone on your way to evaluate the patient What are the one or two most critical concerns What specific orders would we recommend Learn the importance of communication.

4. �How to Sound like a Doctor June 22nd� Strategies: Respond to questions with your own questions These questions should stall for time and create the pretense that you are quite knowledgeable and experienced in the matter at hand Write orders that will stall for time and create the pretense that you are quite knowledgeable and experienced in the matter at hand

5. �Types� of Nursing Calls Vital Signs Blood pressure Heart rate Respiratory rate Temperature SaO2 Urine Output Pain �Dead�

6. �Types� of Nursing Calls Cardio/Pulmonary Chest pain Arrhythmia Shortness of breath Hemoptysis GI Bleed Abdominal Pain Nausea/emesis Diarrhea Constipation

7. �Types� of Nursing Calls Neuro/Psych Unresponsive Agitated Can�t Sleep Fall Seizure Other Abnormal Labs Can you come talk to this family who has no idea who you are please? Calls Just to Annoy You

8. Proper Sign Out Patient Name MRN Major Diagnoses Major Medications Anticipated Problems Don�t forget your patients� sleepers, prn pain meds, expiring meds, etc. �Appropriate� To-Do List CODE STATUS

9. 1. High / Low Blood Pressure Questions Baseline BP? Type of patient? CHF CVA HTN crisis Meds? What IV fluids?

10. Altered BP

11. Low Blood Pressure Ensure adequate IV access Two 18G antecubitals, PICC? TLC? Start with IVF Bolus: 500-1000cc NS over 5� 30 minutes 250 if EF < 40 Repeat up to 2-3L�then think about what�s happening Pressors Norepinephrine (2�40 mcg/min) Dopamine (10�20 mcg/kg/min) Vasopressin (0.04 units/min) Steroids?

12. High Blood Pressure Systolic < 160: No routine need to treat on call Try to find the cause (pain, anxiety, Cubs on TV) Treatment Options Give scheduled meds early Amlodipine 5mg PO Metoprolol 5 mg IV / 25mg PO Look at HR and if pt has RAD/COPD/asthma exac. Captopril 6.25 mg PO Look at creatinine Hydralazine 10 � 40 mg IV/IM Other Lasix, NTG, esmolol, nitroprusside, labetalol, HD

13. 2. Respiratory Problems(??RR, SOB, Low O2 Saturation) Questions Recent sedatives/narcotics? Recent respiratory treatments? In�s and out�s Does the pulse oximeter correlate with the pulse? Did you check the pulse oximeter on your own finger? �The Look� ? GO AND SEE THIS PATIENT

14. Respiratory Problems Main Concerns COPD/Asthma Pneumonia/Aspiration CHF/Pulm edema PE Pneumothorax Large effusion

15. Work-Up Diagnostic Listen to story and to pt Focused exam (stat portable) CXR ABG Trial of Oxygen Therapeutic Bronchodilators Supplemental O2 Diuresis CPAP Intubation Call your senior

16. Basic Vent Orders Typical settings AC/VC rate 12 (bpm) TV 500 � 700cc PEEP 5 FiO2 100% SIMV + PS (10)

17. Ventilator Trouble�Shooting Rule 1: STOP THE BEEPING Call RT to help figure out alarm While waiting� exam check tubes try suctioning ensure sedation stat CXR If all else fails, disconnect vent and bag the patient If can�t bag, call for help!

18. 3. Fever (>38�C, 100.4�F) Infection Meds CVD Malignancy Central fever

19. Questions Is this new? When was the patient last cultured? Blood x2, UA and Cx, +/- CXR if not within 24 hours Check lines Stool if diarrhea Is this neutropenic fever? ANC <500 ? Imipenem (500mg IVPB q8H) STAT Examine perineum, but DO NOT rectalize

20. What antibiotics are already on board? Holes in coverage? Don�t be afraid to treat for patient comfort Tylenol (650mg q4) Ibuprofen (600mg q4)

21. 4. Low Urine Output (<1cc/kg/hr) Questions Foley? Incontinent? Bathroom Privileges? Weight � now versus admit? Concerns Dry vs. Renal Failure (will lasix help either?) < 500 cc per day = oliguria ? Obstruction Check a post�void residual and if > 200cc, leave foley catheter in place Flush foley catheter if present

22. 5. �The Patient is Dead� Is the patient DNR? Are they really dead? May ask family to leave the room Check: Response to loud calling of name and noxious stimuli Pupillary & corneal reflexes Carotid pulse, Heart sounds Breath sounds, spontaneous breaths Family there? Call family AND attending Death Note Sign death certificate in am

23. 6. Chest Pain / Arrhythmias Questions New and comparison 12�lead EKG Cardiac History? ASA and �-Blocker today? K and Mg levels and when were they drawn? Life�Threatening Causes MI PE Pneumothorax Aneurysm

24. Chest Pain / Arrhythmias Talk to the patient If suspicious for cardiac: SL NTG q5 minutes until chest-pain free (up to 3 times) Aspirin (chew two 81mg tabs) Morphine 2�4 mg IV for pain relief O2, serial ECGs Cardiac enzymes (troponin) Heparinize if no contraindications Consider CCU and nitro drip (start at 10 mcg/min and titrate up)

25. 7. Abdominal Pain/N/V/D/C Questions New / Recurrent Blood? New Meds Is there a student on the case? (i.e. is the patient impacted?) Don�t Miss �Acute Abdomen� Ischemia Clostridium difficile

26. Abdominal Pain/N/V/D/C Treatment Options Nausea/Vomiting Zofran 4 � 8 mg PO/IV q 4�6 PRN Reglan 10 mg PO/IV q 4�6 PRN Phenergan 12.5-25 mg PO/IM q4 PRN Compazine 5�10 mg IV q6 PRN Ativan 0.5-2 mg PO/IV q8 PRN Benadryl 25-50 mg PO q6 PRN Consider an NGT

27. Abdominal Pain/N/V/D/C (continued) Diarrhea Psyllium 1tsp-1tbsp (in 8 oz) daily-TID Loperamide 4 mg PO Contraindicated if infectious etiology Check C. diff toxin assay Constipation Colace 100 mg PO BID (prevents - doesn�t treat) MOM 15-30 cc PO Dulcolax 10 mg PO PRN Magnesium Citrate 120-240 ml Lactulose Enemas (tap water, soap suds)

28. 8. Unresponsive/Agitated Patient �Mental Status Changes� Questions Vital signs (+ SpO2) Acute vs. Baseline New Meds Accucheck Common In�Hospital Causes Infection Metabolic Bleed

29. Unresponsive/Agitated Patient Reflex Evaluation Narcan? Simple �Sun�Downing� Haldol 2 mg IV/IM/PO Stop meds CT if ANY focal findings Consider 1:1 sitter Turn off TV and lights, etc.

30. 9. Patient Can�t Sleep Special Concerns Before Medicating? Suggested �Sleepers� Is there an order for a sleeping med? What has worked before? Criticize Colleagues in the AM Specific Recommendations Ambien 2.5 � 10 mg PO Benadryl 25 � 50 mg PO/IV Restoril 7.5 � 30 mg PO Haldol: 1 � 2 mg IV (esp. if > 75, MS changes, dementia)

31. 10. �Patient Fell� Examine the patient and recreate the scene Consider CT scan of the head Patient on anticoagulants Head trauma Mental status changes Neurologic deficits Assess medications Were the guard rails up? Are restraints needed?

32. 11. �NG/Dobhoff tube is out� Why does the patient have an NG? What medications are ordered per NG? Can they be switched to IV? Should I replace the NG? Don�t forget to re-confirm

33. 12. Electrolyte Disturbances High Potassium Check renal function ? ECG Treatment? IV insulin/glucose Calcium gluconate Kayexelate Bicarbonate Dialysis Low Potassium Cardiac History? Check Creatinine Replacement? 10 mEq = 0.1 mmol/L Low Magnesium 1 g = 0.1 mg/dL

34. Electrolyte Disturbances, continued ?? Sodium Assess volume status Exam Net I/O ? Weight ? Sodium Treatment ? = free water ? = restrict

35. 13. Expiring Meds/Restraint Orders Who is the primary service? When was the last dose? Next dose? Are the meds being allowed to expire on purpose? Does the patient need restraints?

36. 14. Blood/Procedure Consent Who is the primary service? When is the blood to be given/procedure to be done? Necessary? Foreseen? Already done? Is the patient able to give consent? HIV ~ 1:500,000 Hep B ~ 1:63,000 Hep C ~ 1:100,000

37. Blood Transfusions Premeds May consider if previous reaction to packed red blood cells Platelet Transfusions Tylenol 650 mg PO Benadryl 25�50 PO (not IV) If fluid overload is a concern: Lasix 20�40 mg IV between units Give unit over 3�4 hours

38. Blood Transfusions Mild chills/rigors Demerol 25�50 IV Serious reaction (temperature spike, pain, hemodynamic instability) STOP transfusion Give IVF Call Blood Bank

39. 15. Pain Meds What kind of pain? New versus Chronic/Recurrent? What has worked before? Is there an order for a pain med? What�s on signout?

40. 16. Alcohol Withdrawal Minor Symptoms Tremor Irritability Anorexia Nausea Major Symptoms Seizures Confusion Agitation Autonomic instability Fever

41. Treatment of alcohol withdrawal Ativan 1-2 mg IV q 4 minutes Titrate as needed until calm but awake Start a drip if necessary (Diazepam, too) Librium PO is long acting alternative Contraindicated with renal dysfunction Thiamine/Folate/MVI (banana bag) Clonidine 0.1 mg PO QID for autonomic instability (may increase to 0.4 mg QID) Last Resort: Propofol 1-5 mg/kg/hr Consider intubation if needed

42. 17. Hyper/hypoglycemia 70 � 200 is Fine! Nobody dies of a BG > 200 overnight. Too low, however, is a fiasco. Too High Regular Insulin or Aspart/Lispro 200 � 250 give 2�4U; 250�300 give 4�6U, etc. If >400, make sure patient is not in DKA

43. Hyper/hypoglycemia Too Low Juice if they can eat or 1 amp D50 Repeat accucheck in 15 minutes If still low/recurs, start D5 or D10 drip HOLD oral agents and insulin! Recheck at least hourly and consider ICU transfer

44. 18. Seizures Give Ativan 2 mg IV/IM immediately Repeat Q 2-5 minutes as needed If persists > 10 minutes = �status� Fosphenytoin 20 mg/kg IV given at 150 mg/min Call Neurology Work�Up ABG, glucose, CBC, electrolytes, tox screen, CT scan R/O trauma, CVA, infection, drugs, metabolic disturbances