Ask A Question

 

If you have a question about something not yet available on this blog, please ask your question in the comment section below. Your question may even be the inspiration for a new blog post that helps switch the lightbulb on for many others!

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48 thoughts on “Ask A Question

  1. Hi Joanna!

    Have a question about your experience regarding dressings form central venous catheters. I work in a cardiothoracic ICU and it is not uncommon for our patients leaving the OR white 1 central venous catheter, 1 dialysis catheter and 1 introducer (for PA-catheter or pacing) all jammed in the internal jugular vein. I still haven’t seen a good way to fixate and get a good seal white our current dressings when i have more than one or two lines at the same place.

    Best regards
    Henrik ร…berg
    ICU-nurse
    Sweden

    Like

  2. Hi Joanne,

    Your site looks great, and very helpful to reboot the knowledge base again.
    Could you please explain the D-Dimer test and what D-dimer is exactly
    Kind regards
    katherine

    Liked by 1 person

    • Hi Katherine,

      When a clot is formed within our body, body begins the process of breaking it down. This results in fibrin degradation products (FDPs) being released into the system, as stabilised fibrin is what is able to “catch” platelets circulating the system to form the clot in the first place. A subset of FDPs is D-Dimer.

      The test is usually done in relation to diagnosing blood clots within the body. However, an elevated value can be a result of numerous things in the hospitalised patient and is therefore not specific to a clot. As such, it is most commonly utilised to RULE OUT a clot within the body when it is not elevated.

      I hope this helps! I’m glad that you’re enjoying the website and find it helpful ๐Ÿ™‚

      Jo

      Like

  3. Hi Joanne!

    My name is Katherine and I am a new graduate nurse that had been working in ED. I was just hoping to get some advice/tips from you on how to recognize and prioritize patients and their needs. Being new to nursing and also ED has me asking myself millions of questions with no answer so I was hoping you might have some tips for me to help me settle in to the nursing field and the high stress levels of emergency! Thank you in advance and I hope to hear from you when you have a a spare moment ๐Ÿ˜Š

    Liked by 1 person

    • Hi Katherine!

      Welcome to the nursing profession! As you’ve probably observed in ED, assessment is very much about an ABCDE primary survey followed by a focused secondary assesment.

      With an ABCDE approach, always fix the problem identified as you go. Your priorities are also very much in order of ABCDE.

      With every patient, a quick ‘end of bed’ ogram will give you a quick snapshot of your patient. If your patient is able to talk to you, their ABCDE’s are most likely stable at the moment, so you can take a moment to gather your thoughts. Think:

      A: is their airway compromised?
      Can they talk to you? Is there gurgling, snoring or any other obstructive sounds? Has the patient got any issues that will compromise their airway eg. decreases conscious state
      If their airway is compromised, fix as you go: airway manoeuvres (head tilt/chin lift or jaw thrust) and airway adjuncts (guedel or nasopharyngeal, suctioning etc)

      B: is their breathing compromised?
      Pop your both hands on their chest to assess if there is equal rise and fall of the chest bilaterally, while there feel for subcut emphysema, count their resp rate, ausculatate their lungs, pop an oxygen sats probe on
      If their breathing is compromised, fix as you go: apply oxygen is sats are low, consider flow support if increased work of breathing, consider any adventitious breath sounds and manage accordingly eg. expiratory wheeze with Ventolin etc

      C: is their circulation compromised?
      Pop some monitoring leads on to see what the heart rate and rhythm is, while feeling the pulse take note of patient peripheral temperature, cap refill and colour, check their blood pressure, consider their central temperature
      If their circulation is compromised, fix as you go: gain IV access, manage any arrhythmias according to the current guidelines, manage the blood pressure if demonstrating signs of haemodynamic compromise with fluids +/- inotropes and/or vasopressors, warm or cool as required

      D: has any disabilities been considered?
      Check their GCS, pupils, any other neurological issues, pain, blood sugar levels, any injuries
      If their disability assessment is compromised, fix as you go: revert causes of altered GCS if possible, manage seizures etc, rectify abnormal glucose levels

      E: has the patient been fully exposed?
      Check for internal and/or external bleeding, check calfs for redness/swelling etc, check for any injection sites or bites etc

      When you start, you’ll have to assess many patients before this primary survey becomes an efficient process. If each area is assessed with no compromised, move quickly to the next. The aim is to eventually be able to get through the primary survey within 2-3 minutes (not counting time for intervention)…but this definitely takes a lot of practice! It will be much slower until you have your assessment approach as second nature: ABCDE and fix as you go! Once primary is completed, come back to a secondary focused assessment to fix any problem areas and have a closer look at things that may have been missed with the initial assessment.

      Good luck with your ED rotation! It will be a steep learning curve, but hopefully a rewarding and enjoyable one! Ask lots of questions as there is never such a thing as a silly question when it comes to patient safety ๐Ÿ˜Š

      Jo

      Like

  4. Hi Joanne,
    I truly enjoyed reading and studying your blog posts. I am teaching BSN students in South Korea–You have INTERNATIONAL readers/followers! ๐Ÿ™‚
    Now I am having some trouble to explain chest tube drainage system, especially the negative pressure transmitted to the patient’s pleural cavity–why the height of the water column in the suction control chamber exerts”negative” pressures? I think I kind of understand what that means in general, but cannot explain how exactly the pressure works. Could you explain that for me?Thanks!

    Liked by 1 person

  5. Hi Joanna,
    Been doing a bit of self education on CRRT and TPE recently. Your blog on CRRT helped a lot and now I am much more confident with CRRT management. I have encountered TPE a few times and found that most of my colleague felt uncomfortable with it – so do I! Would you be able to write on the topic of TPE as well?

    Liked by 1 person

    • Hi Sophie,

      Thank you for the suggestion. I will definitely keep this topic in mind for one of the upcoming posts. Apologies for the delay in replying, it has been a busy start to the year and I can’t believe that it’s half way through March already!

      Liked by 1 person

  6. Very interesting thank you! You write wonderfully and very informative.

    I was wondering in homesetting, patients can use a portable oxygen concentrator (POC) if the need higher FiO2. Mostly used by COPD patients.

    But what if a patient doesnโ€™t have a problem with oxygenation, but with ventilation. Theyโ€™ll probably use a BiPap, but thatโ€™s not really the same use as a POC, since it canโ€™t be used outside while doing grocery shopping and social things like talking.

    Is there a portable machine to use in home setting when a patient has problems with ventilation? So a portable oxygenconcentror but instead of extra oxygen they get a higher flow rate with FiO2 of 21%?

    And second question:
    Will a POC with 1 lpm setting, so FiO2 of 24% be harmful in a patient with normal oxygenlevels? Or will it to little to matter much?

    I really hope you have the time to answer! Thanks ๐Ÿ™‚

    Like

  7. Dear Madam,
    Thank you for educating us all via the blog.
    Please help me with ventilation concepts. CPAP, BiPAP etc. The settings, concept, why it’s needed, who needs it, weaning off process etc

    Liked by 1 person

    • Hi Devki,

      Apologies for the delay in responding; work and life have been relentless for the back half of last year! I will be planning on writing more consistent blog posts this year and will put this down as one of the topics to discuss.

      Thank you for your question!

      Like

  8. I have a question about the use of Calcium in the pathway. You mentioned in your article that any arrows going from 2,7,9, and 10 require Clacium. In the diagram, it looks like the red arrow (which I’m assuming is calcium) is pointing from at Fibrin which is Factor I? I might be misunderstanding that section and was hoping you could clarify for me! Thank you!

    Liked by 1 person

    • Hi Martina,

      Apologies for the huge delay in responding; work and life have been relentless for the back half of last year! The red arrows indicate clotting factors that have to be present in order for that part of the clotting cascade to continue. So the red arrow between Fibrin and Stabilised Cross-Linked Fibrin requires factor 13 to be present.

      Hope this helps!

      Like

    • Hi Theresa,

      Apologies for the delay in responding; work and life have been relentless for the back half of last year! As things have settled more, I will have more time to start writing articles on this blog again. I will put this on the list of topics for discussion!

      Like

    • Hi Edan,

      Apologies for the huge delay in responding; work and life have been relentless for the back half of last year! The big differences between bipap and airvo are as follows:

      1) BiPap is a closed system that will generate higher amounts of Positive End Expiratory Pressure (PEEP) if there is an adequate seal on the facemask – Airvo can generate small amounts of PEEP with the highest flow settings and only if the patient keeps their mouth closed to mimic a closed circuit
      2) Bipap will allow the dial up of pressure support within a closed circuit that significantly aids work of breathing –
      Airvo doesn’t deliver pressure support, only high flow
      3) Bipap can augment the delivery of flow based on the breath to a higher amount than 60 L/min – Airvo to a maximum of 60L/min
      4) Bipap will allow 100% of oxygen concentration to be delivered to the patient as required due to it’s closed circuit – Airvo will have it’s limits with the ability to do this
      5) Bipap can augment larger tidal volumes based on increasing pressure support to drive a higher peak inspiratory pressure – Airvo depends on the patient to help drive their own volumes with the assistance of extra flow
      6) You can’t eat or drink with Bipap – you can with Airvo
      7) People can feel more claustrophobic with Bipap – not so much with Airvo

      Generally, Airvo is more comfortable for the patient. BiPAP will be required if you want to generate higher PEEP (APO for example), if you want to deliver a higher concentration of oxygen (worsening oxygenation issues that have not yet resulted in respiratory failure), if you want to give the patient extra ventilatory support to reduce WOB that is not being met by high flow, and if you want to augment larger tidal volumes with a patient that still has their own inspiratory effort.

      Hope this helps!

      Like

  9. Hello Joanne,
    working in a trauma unit we get quite a few patients with neuro trauma. Often they go into DI. My question is what are, how to calculate, and what is the relevance of urine and plasma osmolarity?

    Like

    • Apologies about the delay in responding to this question!

      In order to understand third spacing, there needs to be an understanding of the difference between the intracellular and extracellular space. The extracellular space consist of the intravascular compartment and the interstitial area. When you give a patient IV fluids, you are wanting it to stay in the intravascular department. However, sometimes you find that this is not the case. Fluid shifts from the intravascular into the interstitial spaces, the space between the intravascular department and the intracellular department. This accumulation results in what we see as oedema.

      In sepsis, your intravascular wall linings become “leaky” due to the various inflammatory mediators within the blood stream. There is also a possibility that the balance between the hydrostatic pressure (pressure that pushes fluid out of the intravascular space) and oncotic pull (pulling force that brings fluid back into the intravascular space) is lost; leading to fluid moving out of the intravascular space and not being able to be re-absorbed back in. This concept of fluid moving from what will help the blood pressure (intravascular department) to an area that will just retain the fluid without any benefit (interstitial department) is what we refer to as third spacing. It doesn’t happen only in sepsis, you can see it when a patient a large inflammatory response (big abdo surgery, cardiopulmonary bypass etc).

      I hope this answers your question ๐Ÿ™‚

      Like

  10. Hi, I just found this blog and it’s brilliant. Am doing ICU post grad and googling some of the concepts I need to know, and your explanations are really good! I notice there’s no recent new posts, so I’m not sure if you still update this blog or not- I’ll be checking back anyway to see if there are! (I can also provide plenty of suggestions for new topics!)

    Like

    • Hi Simone! Thank you for your lovely feedback! I have been absolutely snowed under with work (with all those ICU post grads starting), but still aim to be back posting regularly in March! Feel free to put forward as many suggestions as you like, they are always welcomed! Good luck with your course; it’ll be the busiest but most rewarding year!

      Like

  11. Jo, thank you for your time on my behalf. Since our staff may/ may not transition to grad school- I’m needing to build/ structure a comprehensive model to help them become ICU generalists. I’m thinking of making a passport- with each system being a country so to speak, with certain skills needing to be addressed and mastered… Anyway, I appreciate your help- you’ve given me lots to think about.
    Thank you!
    Kerri

    Liked by 1 person

    • I like the passport idea! Very creative! And gives each person an incentive for completion! Perhaps the teaching could occur in themed months: January and February for Respiratory, March and April for Cardiac…so on and so forth! I hope that it all works out ๐Ÿ™‚

      Like

  12. Joanne,
    Thoroughly enjoy your blog. So well thought out and delivered, Thank You falls short. I fully appreciate your quest to educate in a clear and demystifying manner. being an ICU educator as well. A couple questions –
    I provide an ” article of the month” for the staff- Is it possible to have one of your articles /blog posts used in this manner? I would provide the link and any information you would like. Thoughts? the posts are so on-point and valuable i would love to share.
    Also,
    I would like to create a pathway for generalist ICU nurses from novice to proficiency- over 2-5 year span. Are you aware of anything “out there” to help accomplish this by any educators? I have some ideas but do not want to re-invent the wheel if such a pathway exists.
    Thank you,
    Kerri Tillquist

    Liked by 1 person

    • Hi Kerri,

      Thank you so much for your lovely feedback! I am more than happy for you to include any of my articles for the purposes of education through your unit; it is truly the greatest compliment! Also, I am always on the lookout for topic inspirations…so please feel free to let me know if there is anything specific that staff tend to ask a lot of questions around.

      In terms of the pathway of novice to proficiency in the generalist ICU nurse, I think it really depends on each unit’s requirements and the overall workforce. In my current unit, there are various programs that provide nursing staff with a steep learning curve. There is an intro to ICU which is 6 months of front loaded theory and 6 months of consolidation, with the intention of moving these nurses into post graduate studies for the following year. The intro program tends to be similar to the content of the first semester of the post grad, minus the academic writing. There is also a transition program for nurses with a post grad in a different area that focuses on the hurdle requirements around management of ICU patients.

      After the clinical knowledge is learnt, it is about consolidation of skills and preceptorship to the next influx of junior staff. This leads into leadership courses for those that move into a CNS role or team leader role. Usually the step up into a leadership role that demonstrates proficiency and role modeling normally takes around 3-4 years…

      I’m not sure if this is the type of information that you were after, or if I have completely misinterpreted the question…

      Jo

      Like

  13. Dear Joanne
    I am really struggling to understand gas flow rates. I have read your blog on how flow rates determine FiO2, but my struggle is what the flow rate actually means. For example does 12l/min mean that 12l of gas is actually going into the patient per minute? The reason I don’t think this is the case is because when transporting patients on High Flow Nasal Cannula we cannot possibly have enough gas to last a 30 minute journey as that would need 360 litres.
    Many thanks, Amy

    Liked by 1 person

    • Hi Amy,

      Flow rates are exactly what you have described. If at 10L/min…that means that 100L has been delivered in 10 minutes. A standard bottle of oxygen actually holds around 470L of gas. So even running at 15L/min, you still have 30 minutes of uninterrupted transport time. It’s for that reason that most people will swap to wall oxygen during a CT or MRI, so they can preserve what’s in the cylinder for the return trip (or take an additional oxygen cylinder for backup).

      Hope this helps!

      Jo

      Like

    • Thank you for your lovely comment Lindy ๐Ÿ™‚

      It is fabulous to hear that the articles are helpful and that people are enjoying reading them!

      Please feel free to request any topics that you might find useful because chances are, someone else will find the same topic useful as well ๐Ÿ™‚

      Jo

      Like

  14. Hi Joanna,

    Been following ur blog and must say u are doing an awesome job in making critical care topics easy to understand! I would like to understand more about CRRT and searching for the web very technical sites. Will you be able to write on the topic?

    Liked by 1 person

    • Hi Mantabeng,

      Thank you for the great feedback! I’m actually running training within my unit on the concepts of CRR at the moment, so will be easy to put something together for the next post.

      Stay tuned!

      Like

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