330 likes | 336 Vues
Pearls of Cross Cover Jason B. Martin. What is cross cover?. Covering for your partners other interns who are off teams signed out to you at night You are the patient’s primary physician after hours labs, consult recs, consent (blood) family concerns ALL medical and nursing issues
E N D
Pearls of Cross Cover Jason B. Martin
What is cross cover? • Covering for your partners • other interns who are off • teams signed out to you at night • You are the patient’s primary physician after hours • labs, consult recs, consent (blood) • family concerns • ALL medical and nursing issues • The sign out sheet • BRIEF explanation of why patient is here • Just the facts! Don’t editorialize. • Pertinent demographics (name, age, MR, room #) • allergies • CODE STATUS (and keep this up to date)
What NOT to sign out: • Routine daily responsibilities • get your notes done before rounds • Subjective comments • Results that won’t affect patient care • Non-specific plans • RESTRAINT RENEWALS
Responding to pages • Be prompt, especially with tagged pages • Your tone • Irritated? Hurried? Rebuking? • Be polite • What does the nurse REALLY want? • Reassurance? Appease patient or family? • Empower the nursing staff • What do they think is going on? • What should WE do about this issue? • Come to a decision and ask for read-back • Leave tracks in the chart, sign-out sheet
Giving Medications • Do I really need to give a medication? • Does the patient have a medication on his/her list that I can use, or dose early? • Review allergies • Consider renal and hepatic function • General principles • shorter-acting agents are better in the middle of the night • PO > IV • lowest dose to achieve • think about patient comfort and nursing care • Use phenergan and ativan with caution in older patients
You are not alone • Use your resources nurses and techs, residents, fellows, attendings • ALWAYS call your resident if something’s not right • ALWAYS call early • Trust your instincts
Common Questions on Call Disclaimer: This list in NOT comprehensive. Even seasoned veterans can be surprised on call
Common Questions on Call • Insomnia • Constipation • Diarrhea • N/V • Electrolyte problems • Fever • Loss of IV • Decreased UOP • Confusion • EtOH withdrawl • Dyspnea • HTN • Hypotension
Insomnia • Probably the most common call • Consider prn orders at admission • Why can’t they sleep? • pain • anxiety • noise • sundowning • What normally works for the patient?
Insomnia • Antihistamines • Diphenhydramine (Benadryl) • 12.5, 25, or 50 mg (IV or PO) • Benzos • Temazepam (Restoril) 15-30 mg PO great for older pts • Lorazepam (Ativan) 0.5 mg PO, IV • Avoid alprazolam and valium • Zolpidem (Ambien) 5-10 mg po qhs prn
Constipation • Review medication list review with AM team • Iron • CCB • Laxatives • Bisacodyl (Dulcolax) • 5 or 10 mg pr • Docusate Sodium (Colace) • 100 mg po BID • Milk of Magnesia • 30-60 mL PO • Metamucil
Constipation • Lactulose 10-20 grams (15-30 mL) • Go easy • Tastes bad • Dramatic results • The Green Bomb: Magnesium Citrate (300 cc bottle) • Fleet’s Enema • Don’t order it • Just use soap suds • Avoid Mg-containing compounds in renal failure
Constipation • Attention Interns: • The patient may need manual disimpaction.
“Diarrhea – Cha! Cha! Cha!” • Is it diarrhea or just loose stools? • Associated with fever or leukocytosis? • c.diff? Start empiric flagyl? • hemorrhagic colitis? • Leakage around an impaction? • Avoid anti-diarrheals acutely • Immodium or lomotil if needed
Nausea and Vomiting • Promethazine (Phenergan) • 12.5 – 25 mg PO/IV q 4-6 hours prn • Caution in elderly • Metoclopramide (Reglan) • 5-10 mg PO • Lorazepam (Ativan) 0.5 – 1 mg PO • Serotonin antagonists (Anzemet, Kytril, Zofran) are available • generally second-line ($) • oncology patients • refractory cases
Hypokalemia • Hypokalemia • normal range is 3.5 – 5.0 • replace PO/per tube when possible (immediate and SR forms) • can replace IV if necessart • be aware of patient’s renal function • be aware of any standing K orders • conisder empiric Mg replacement if refractory
Hypokalemia • KCL immediate release orally 40-60 meq is a standard dose • powder/elixir rapidly absorbed • tastes terrible; patients with nause may not tolerate • Kdur tablets • slower onset, longer-acting • IV KCl it hurts • slow replacement (10 meq/hour peripherally) • takes the IV port
Hyperkalemia • Hyperkalemia can kill a patient (arrhythmia) • Order EKG (and call your resident) • Does it fit the clinical setting? Hemolysis? • Swift action may be required
Hyperkalemia • Calcium gluconate rapidly stabalizes the cardiac muscle membranes; effect is transient • Insulin (10 units IV) with 1 amp D50 • drive K into cells • onset 15-30 minutes • Bicarbonate • transient cellular shift • Beta agonists • Dialysis
Fever • ALWAYS EXAMINE THE PATIENT • Draw cultures prior to abx • You will rarely be faulted for choosing broad abx; just think about the possible sources • Don’t forget about allergies • Renally dose medications Use Sanford Guide
Loss of IV • Does the patient need an IV? • Any meds scheduled for tonight? • Ask for IV therapy to assist (at VU) • Attempt yourself? • Can you convert to PO? • What about a central line?
Low UOP • Is the Foley placed properly? • Flush the Foley • Reposition it • Assess patient’s volume status and read the history • volume overloaded Lasix • crackles, elevated JVP, S3, edema • volume depleted NS • orthostasis • hypotension • tachycardia • Get your resident involved if unsure
Chest Pain • Huge differential diagnosis from annoying to life-threatening • Always evaluate CP in person get out of bed • Have the nurse get EKG while you are on your way • Think about GERD, PE, MI, dissection, anxiety • Assess vital signs, careful physical exam • diaphoretic? • dyspnea? • acutely ill-appearing? • pleuritic?
Chest Pain • EKG changes? Call for help Time is myocardium • Cardiac enzymes • CXR • Transfer to another unit? • If you think it’s cardiac: • ASA • nitro spray or SLNG in new pts, ask about sildenafil use • O2 • morphine • βBs
Dyspnea • Always examine these patients in person • Vitals (RR and sats) • Huge differential • failure, edema • bronchospasm • PE • ptx • MI • pneumonia • bronchospasm • acidosis • anemia
Hypertension • Urgency, emergency, or no big deal? • Physical exam • BP in both arms • funduscopic exam • rales? • neuro exam • Labs / Imaging • BMP • EKG • UA • CXR • AMS or focal neuro deficits CT head without contrast
Hypertension • Is the patient in pain? Anxious? • Use current medications • early dosing • increase doses • Clonidine it works, but no style points • 0.1 mg to 0.3 mg po • Nitro paste • IV push (with consultation): labetalol • IV gtt (with consultation): cardene, nitroprusside
EtOH Withdrawl • Can be life threatening • Be suspicious: agitation, tremor, hypertension, tachycardia in a drinker • Treat with IV benzos • Start low, titrate rapidly to achieve effect (Protocol in place?) • Ativan IV: 2 mg 4 mg 6 mg 10 mg • MVI, thiamine, folate • Consider transfer to a monitored unit
Confusion / Delerium • Check VS, sats, glucose, consider ABG • Discuss with nursing staff, family what’s the baseline? How acute is the change? • Why? • hypoglycemia • recent fall? CT head? • infection? • medications? • ICU or hospital-induced delerium • EtOH withdrawl • iatrogenic (phenergan is a common offender)
Confusion / Delerium • Sundowning • very upsetting to families • can worsen with ativan • best therapy family and reassurance • restrain for patient / staff safety • try some haldol
AVOID • Demerol • Major changes in plan without consultation • Treating patients without examining them • Short temper with nurses • Calling for help too late
Intern Companions • Hemoccult cards, developer (and a gentle touch) • Opthalmoscopes and tropicamide (Mydriacyl) • Motivated medical students • A supportive resident: • “ If the horse dies, the cowboy walks.”