GFR

Now that I am in the radiology department I spend a lot of time focusing on GFR and kidney function. Why? Good question!

In MRI and CT we give contrast to a lot of patients. In CT the contrast is iodine based. In MRI the contrast is gadolinium (metal) based. Both types of contrasts are filtered out through the kidneys and thus the reason kidney function is so important in this department. The way we assess kidney function is by checking a patient’s creatinine level in their blood. Luckily for us we have machine called the i-Stat that can test the blood and give a result in two minutes. The result transfers into Cerner (our EMR) and the computer then uses that result to calculate the GFR. Great… except I didn’t really have an understanding of why we were checking the creatinine, what GFR really was, or why there is a GFR result for African Americans and non-African Americans. I decided to do a little reasearch and I figured, since this is a nursing blog and all, why don’t I share what I have learned?

What is “GFR”?

GFR stands for glomerular filtration rate. Basically, the GFR tells you the flow rate of fluids through the kidney. Your glomeruli are the capillaries in your nephrons inside the kidney. Blood is filtered across the capillary membranes helping to remove waste that can ultimately be excreted through the urine. Taking you back to anatomy and physiology in nursing school aren’t I? *shudders*

A simple google search will bring up lots of GFR calculators. Typically the GFR calculator takes into account serum creatinine, age, gender, and race (African American versus not) and then it will give you the estimated GFR. A GFR >60 indicates a generally healthy kidney. Less than 60 can indicate potential kidney disease. Less than 15 can indicate full on failure. Here is a little infographic that is patient centered.

Why creatinine?

Why does the GFR equation use creatinine? In the most basic terms, creatinine is a waste product of creatine. Creatine is used by the muscle cells for energy. Your kidneys help filter the creatinine out of the blood to be excreted in the urine. Low creatinine typically indicates good kidney function (which makes sense, healthy kidneys will filter out creatinine effectively). High creatinine indicates the opposite, kidney function is probably on the lower end because the kidneys are unable to filter out the waste product. Creatinine is primarily filtered out through the kidneys which is why it is a pretty good indicator of kidney function.

Why is the result different based on race?

Many, many times I have looked at my labs and wondered why the GFR had a result for African Americans and then essentially everyone else. It wasn’t until I started working here and paying attention to the GFR that I decided to look it up. Turns out studies show we have “higher than average” muscle mass so we generate higher levels of creatinine. Higher creatinine levels lead to higher filtration rates. The difference in results account for this.

Now I can actually explain to my patients why I am taking blood after I start an IV. I like to be able to asnwer my patient’s questions so of course I had to do a little learning on my end. Hopefully some of you will also find this information useful! (Also here is a great reference for frequently asked questions from the National Kidney Foundation because, why not!)

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Look at me when I’m talking to you!

I am going to vent for a moment so bare with me okay?

I ABSOLUTELY HATE WHEN MY PATIENT DOES NOT LOOK AT ME EVEN ONCE WHEN I AM SPEAKING TO THEM!

This has nothing to do with eye contact. I know for some people, eye contact is uncomfortable or unusual in their culture. I get that. However, when I call someone into my IV chair and they can’t bother to put their  phone down long enough to raise their head and answer my questions it burns me up! I just feel like it is so disrespectful! Is that how they converse with everyone? No, I highly doubt it. I think *that* is what bothers me the most. I am simply trying to provide care within my environment. I didn’t force them to come to this hospital, nor did I force them to make an appointment for whatever reason they are here. I feel like the least someone can do is acknowledge that a human being is standing in front of them providing care.

There have been times when I am trying to go over information with a patient and they are so engrossed in whatever is happening on their phone that they have a hard time answering my questions. Typically this statement will get me the acknowledgment I prefer: “Let me know when you are done on your phone and then I I’ll continue.” After that I take a step back and wait. Patients will typically put the phone down and pay attention.

In all honesty, I don’t need their undivided attention the entire time they are in my care. Since I am the radiology nurse, I am going to be the one to go over the contrast questionnaire with the patient and then I will obtain vascular access. This isn’t dramatic stuff here. I really only need the patient to pay attention when I am asking them questions, after that I actually prefer they occupy themselves because most often it means they’ll focus on their phone and not on the 20g I am about to stab them with.

I don’t know, maybe I’m just getting old or something but a little acknowledgment wouldn’t hurt.

Uniform… Acceptance…

The hospital I work for has a uniform policy. As nurses we wear ceil blue and/or white. I hated the idea of uniforms… At first.

Now, I kind of like the fact that each department in our hospital has a uniform.

Yeah, it surprised the hell out of me too!

It helps me know who I’m talking to or who just walked into my patient’s room. I’ve often had patients say, “the doctor said I can have something to eat!”, however I haven’t seen the docs come onto the unit. Now I’m trying to figure out who my patient was actually talking to so I can find out what was actually said. With everyone being in uniform I can ask my patients “what color uniform were they in?” I cannot tell you how many times I’ve asked that question and then find out it was xray technician that came in to do the morning portable chest xray that the patient talked to! For a lot of our patients, anyone in scrubs is a doctor.

The fact that I can identify a department just by their scrubs is a real help and as much as I hate to admit it, uniforms made things a lot easier. I only have one big complaint, THESE COLORS!!!!

I despise the ceil blue/white combo. I would really prefer a darker color. Something like a hunter green or a navy blue would work for me but it is what it is.

So tell me, what policy did you initially hate that you’ve learned to accept and perhaps even like?

Decisions

I think I finally made my decision about going back to school. I completed my bachelor’s degree last year and have been on the fence about getting my master’s degree. Is it worth it? What path should I take? I just couldn’t make a decision.

I think I know what I am going to do. I’m going back to school.

At first, I planned on either following an education or leadership path. I think that is going to change. I’m going to try to get into a nurse practitioners program.

After talking to lots of other nurses that are currently in school, nurses with their master’s degree already, and lots of research, I realize my career path is far more flexible if I have my advance practice degree.

I think I stayed away from the idea of an NP program because I had a very narrow idea of what nurse practitioners can do.

My views are changing. Being around a lot of wonderful NP’S in my career had shown me they do a whole hell of a lot. NP’S make a difference. I want to make a difference. I think I’m going to really give this a shot…

OR 4

I’ve been shadowing in the pre and post op unit for the last week. I am still a radiology nurse but I’m up here learning a few things. In MRI we give some of our patients propofol to sedate them so they can tolerate the scan and then we recover them afterwards. My department has me floating in PACU to evaluate how PACU recovers patients to see if there are things we need to bring back to our department. I’ve been enjoying myself so far. Today I am following the sedation nurse. We are in OR 4.

OR 4 is where they are doing all the abortions today.

I wasn’t prepared.

I have no children and have never been pregnant. I have no desire to have kids. Honestly I’m not fond of them. I am pro-choice. I consider myself pretty liberal. I don’t judge women who choose to have an abortion.

I was still not prepared.

I’ve read about abortion. I know people that have had them. However, I have never actually seen an abortion and after today I don’t need to see anymore.

It’s emotional.

One was because of fetal deformity. Most were not. The reason didn’t matter. You could see the anguish in some of the faces of the patients. Some were stone faced and I couldn’t really tell how they were feeling. A 16 year old seemed not to really have a full grasp of what was really happening. One lady cried and expressed her feelings of guilt the whole procedure.

It’s was a lot to deal with.

The procedure itself was different than I expected. Mentally I has to steady my nerves to watch how the fetus was removed. Typically I stayed at the head of the table with the patient for their comfort… And my own. I tried to focus on the patient and not the procedure so I could keep my emotions out of it.

This is definitely something I could not do on a regular basis, if I could ever do it at all. This experience is something I definitely won’t forget.

I still remain pro-choice even after today. Now I understand what women go through not just physically but emotionally when having to make this choice. It’s so much deeper than what I understood.

The complainer

Don’t be the complainer.

You know the one, nothing ever goes right for this nurse. They are the ones that come in and start complaining before they even clock in. They always have the worst assignment. They always have the worst shift. Everything is always wrong.

Two total care patients that only really need repositioning? “OH MY GOD WHY DO I HAVE TWO TOTAL CARE PATIENTS????”

Four walkie talkie patients that are self care? “GREAT THEY ARE GOING TO DISCHARGE SOMEONE AND I’M GOING TO GET AN ADMISSION!”

Float to an easy unit with cool ass staff? “WHY IS IT MY TURN TO FLOAT???”

Go home.

Why are you even here? Why are you even a nurse? What did you expect from the health care field? No, our jobs are not a roses and sunflower fields every shift. Sometimes our jobs suck, horribly. Honestly though, if every shift is your worst shift ever and it’s like that no matter where you work… I hate to be the bearer of bad news but it’s not the job, it’s you.

I mean, you’re the common denominator here. It’s time for you to face the facts: you’re miserable at your job because you’re just miserable as a person. Maybe you should work on that…

n00b

So you’re the newest person on the unit. You may not be new to nursing but you are new to this place. Don’t let that freak you out.

As the newbie I was always really quiet and reserved. What I didn’t realize was how off-putting that was to others. It never failed, once I got to know my coworkers they would all say the same thing “I thought you were so mean when I first met you!” For the longest time I didn’t understand why that seemed to be the case. You know me though, if I don’t know then I’m going to ask. That is when I found out that I sort of appeared unapproachable because of how I tended to distance myself from my new coworkers. I changed that once I started the new position I am currently in. This time I made a conscious effort to get to know my coworkers.

Here are a few steps to transition into your new work environment:

  • Introduce yourself to your new coworkers. If you know of a good ice breaker then use it (having the name Shaunelle but being called Fred is one hell of an ice breaker, everyone loves the story of how I got my nickname.)
  • If you are an experienced nurse understand this: your experience is much appreciated but you are the new nurse on the unit. Don’t walk around like you already know everything there is to know. You may know cardiac ICU but you don’t know how they run their cardiac ICU. Have a little humility (ran into this with a new coworker, she didn’t last long).
  • Don’t be afraid to ask questions. It is safer to ask than to assume you know what you are doing and then do it wrong. Your new coworkers will remember that screw up, trust me.
  • If you are a super proactive person, join one of the committees. You are bound to meet your coworkers that way.
  • Become familiar with your physicians and introduce yourself to them. Let them know you are new to the unit, I mean you will be working with them too.
  • Know that not everyone is going to warm up to you immediately and that’s okay. They may still be “feeling you out” so to speak. That is not your problem, that is theirs. They’ll either come around or they won’t. It’s not the end of your world. However, DO NOT allow bullying behavior towards you. You may be the newbie but you deserve respect and if they want it from you then they should earn it. Forget that “nurses eat their young crap”!

Those first few weeks, hell even first few months, are a weird time. You’re trying to adjust to a whole new setting. Things may feel off and that is normal. You may feel a little out of place at first, and that’s normal too. Give yourself time to get acclimated to your new surroundings, you are going to do great!

ABG’s, what do they mean?

Arterial blood gases… Chances are if you work in a progressive care or intensive care unit you have seen ABG results or you will.

If you’re like me in the beginning, you have no idea how to interpret the results. For the longest time I had no idea what I was looking at. I knew the pH was indicative of acidosis or alkalosis, and that was the end of it. Once I started working in an ICU I wanted to really understand what the results meant. I made one of our respiratory therapist teach me how to understand the results (he was awesome and was happy to help). It turns out ABG results are not too terribly difficult to interpret. You are trying to obtain three key pieces of information:

  • Is the patient acidotic or alkalotic?
  • Is this a respiratory or a metabolic issue?
  • Is the body fully compensating, partially compensating?

While there is plenty of information on the ABG slip (or in the chart if your unit doesn’t have an ABG machine available) you can come up with the answer by looking at three key results: pH, paCO2, HCO3.

One of the ECCO learning modules I did had this handy little chart that made it easier to interpret the results. I thought I would share it with you all in case there is someone out there confused like I was, but may not have a quick resource available.

That’s it. This little handy chart has helped me a lot. It took what was, for me, a larger amount of overwhelming information and broke it down into something I could use. Here’s how to use it:

Look at the pH, is it <7.35 (you’re acidotic) or >7.45 (you’re alkalotic) or is it normal? Circle which side of the chart your value falls in. Then look at the PaCO2. We are looking at carbon dioxide in the blood here. Repeat the previous steps and circle where your value falls. Then look at your bicarb, HCO3. Circle where that value falls.

Remember pH tells you if they are acidotic or alkalotic. Now that you’ve figured that part out, it’s time to figure out if this is respiratory or metabolic. Look at your chart, is the CO2 circled on the same side as the pH? If yes, it’s respiratory. Is the bicarb circled on the same side as the pH? If yes, then it’s metabolic. Now, are we compensating? If you are partially compensating then you will have one value on the other side of the grid. If you are fully compensating then your pH will actually be normal.

I’m a person that needs to see something in action so let’s do a couple of examples:

Note let’s break out the chart:

pH is low so we know the patient is acidotic. The CO2 is on the same side as the pH. The bicarb is on the opposite side of the grid so the body is trying to compensate. We have respiratory acidosis, partially compensated.

Let’s do one more:

Bust out the handy dandy chart!

The pH is high so we know it’s alkalosis. The bicarb is on the same side of the chart as the pH but the CO2 is on the opposite side. Here we have metabolic alkalosis, the respiratory system is partially compensating, that’s why the CO2 is high.

I would like to mention one thing, if all your values are on the same side of the chart then it most likely means the one of the systems of the body aren’t compensating.

Hopefully this post is able to help someone out. If you have any other hints, tips, tricks let me know!

Holier than thou

Hello holier that thou nurse and/or doctor on med Twitter.

We are so glad you came to join us and tell us how wrong we are for sharing our experiences when they aren’t all “rainbow and unicorny”. Let me see if I can explain something to you:

Sometimes it can suck being a nurse. Sometimes it sucks being a doctor. Sometimes it sucks being a CNA. Sometimes, the medical field just sucks.

I know this is shocker for you since your days are only sunshine and blue skies. For the rest of us, however, we deal with patients every day. We see death, abuse, addiction, cancer, and disease progression on a daily basis. We see tears, we get hit, we get verbally abused, we witness (and then somehow get involved in) family drama, we get spit on, we get called racial slurs, we go THOUGH it. Sometimes, we take to “med Twitter” to vent to those that understand us. We don’t do this because we get a kick out of bashing patients. Majority of us in the medical field are in this field because it’s what we love and we couldn’t see ourselves doing anything else. We love what we do but sometimes it’s a bad day and we need to talk about it to other people that have been through what we are going through. We get encouragement. We get advice. We get a picture of a puppy to melt away the stress. It’s our own little online bar where we get to sit and talk to the bartender. We need an outlet.

What we don’t need is your pretend internet holiness and your pretentious “I’m more of a patient advocate than you are” attitude. We would never do or say anything to harm or patients. We are, contrary to your belief, compassionate and caring medical professionals. We use these outlets to keep from losing our minds. So how about you hop on down from atop that high horse, ok?

Vitamin C and sepsis

You may or may not have heard about some new studies coming out that show some positive results adding vitamin C to sepsis treatment.

If you haven’t heard anything about it, don’t worry, you will.

This is what really kind of started it all. It was a retrospective study, not one you could really take back to your ICU and make evidence based changes on, but it provides some interesting factors to think about. This study gives some information about some of the preliminary findings. So far, (cautiously) it looks positive.

However, don’t think doctors around the world are ready to jump on the vitamin C boat just yet. There hasn’t really been a what I would call a “large scale” scientifically sound study completed just yet. It’s safe to say the idea remains controversial. Here is a really good article addressing the controversy surrounding the treatment. I did notice one thing when I read this article: while doctors may not be ready to jump on board do to a lack of evidence, most of them really hope vitamin C treatment does turn out to be beneficial. The health care field as a whole really wants a better treatment for sepsis, especially since what we are doing now is only partially successful.

I am hoping someone decides to do a large scale study and really put vitamin C to the test. I would love to know if this could potentially be an adjunct sepsis treatment or if it is time for medicine to go back to the drawing board. Trying new things is what helped the medical field advance this far, let’s not stop now!