Internship help !!

[BlueJasper]

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There has to be a quick way to reference things/meds that you give to patients. for example, I am in the ICU and we extubated a patient today. His systolic pressure went up to around 165 or so. (baseline around 135 or 140).. the nurse asked me to write an order for his BP.. he was already on metoprolol BID.. she wanted a prn order. I had no idea what to order. She suggested hydralazine 10 mg prn.
Another patient (s/p bone marrow transplant) was in the unit for increased work of breathing and hemoptysis...she had pneumonia... we wrote for a few ABX (vanco, zosyn, levo). Once again, I had no idea about what to order, and the dosage. The same can be said for blood sugars.
Now, I do have Tarascon's Critical Care Pocketbook, Pharmacopoeia, and my pocket medicine, but they don't have quick guidelines for these things (eg-what BP med for what situation, etc)..
please help suggest what I can use as a sure-fast reference..
help..

 

[RussianJoo]

um shouldn't you be learning that sort of stuff from your attendings or text books? I mean this is the end of your intern year, i would hope that you don't have to take suggestions from nurses and can think on your own by now...

 

[RussianJoo]

Then again maybe you're a medical student, cause that's what it says on your status.. in which case it's ilegal for you to write orders especially drug orders so please stop doing that. you might kill a patient.

 

[EternalMD]

It's possible the OP started internship already ... sounds like he just started up and was thrown into the unit and thus not knowing what to do coupled with the fact his previous posts suggest he just went through the match this past year.

So regarding your question, shouldn't your senior be around to help you with these decisions? Do you have epocrates? also, you should think about what the reasoning behind giving medications should be i.e. what is causing his elevated pressures post-extubation, what was the reasoning for choosing those anti-bx? etc.... Start using up-to-date while in the unit and reading up.

 

[Tigerz_Fan]

Agree with the above.

Your senior should be helping you with these things. You do need to learn how to look things up and use references, but you also need to approach your senior regarding orders. Be proactive with your own educaiton. Don't be afraid to ask questions.

You need Sanford Guide and Epocrates to help you with medication dosing (the antibiotic example you gave). Look it up first, and verify the dosage with your senior.

Take advice from nurses with a grain of salt. Some are extremely smart and good at their job, but I learned early on to double check anything they suggested. You gave a good example. As mentioned before, try to treat the unlying cause of the high BP (stress of recent extubation) before giving meds. And besides, hydralazine for a BP of 165 when baseline is 130-140? That is a bit much.

And believe me, during morning rounds, when the attending asks you why you made that particular medication choice, do you really want to tell him because the nurse told you so?

 

[Winged Scapula]

So his BP went up after extubation?

No suprise there, pretty stressful event.

And the nurse wanted you to treat it or you did?

As noted above, 165 is not a problem in a recently extubated ICU patient whose normal pressure is a mere 25-35 points lower.

This was something that didn't need to be treated and if they are calling you SBP of 165, perhaps you need to rewrite your call orders.

 

[Trinity12]

I liked Pocket Medicine. This is an old edition (the new one is red)

http://www.amazon.com/Pocket-Medicine-Massachusetts-Hospital-Handbook/dp/0781744474

I just saw that you already have pocket medicine and the Tarascon books. From what I remember from my ICU rotations, with those 3 you should be able to come up with management for most things you'll see. don't worry about having to look things up. Reading up to date was a good suggestion. Once you look things up a number of times, it will come to you easily. You can try keeping a small notepad and copy down things. Eventually, you'll stop carrying all that with you... it will come in time. Don't worry about it.

 

[michelleDO]

Hey,

I would definitely try to get "internship survival guide" by washington manual. they helped me a lot during my subinternship calls. according to this book regarding your question about hypertension management is

elevated bp alone, in the absence of symptoms or new or progressive target organ damage, rarely requires emergent therapy.

you need to treat the patient. not the bp reading. so in that case think of the differential such as hypertensive emergency and urgency. assess the patient. ask for symptoms (chest pain, sob, disorientation, dizziness, etc), do physical exam, quick look at the chart, you know about his baseline bp already, look at his previous meds. and last but not least think of differential such as:

Drugs: overdose, interactions, withdrawal
PE
MI
Hypertensive encephalopathy, urgency
Aortic Dissection

so again for hypertension, treat the symptoms, not the bp reading.

if any higher ups have anything to add please do so.

hope this helps. and don't be afraid to ask. im glad you did

Michelle

 

[jonb12997]

how about peds, any suggestions for a good book to carry? I have a Harriet Lane, but that's aweful big. Is there anything like Pocket Medicine for Peds??