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| No. 10 | 
Mar 10, 2009, 03:04 PM
 Re: Is this too much or am I crazy...what are your units like? Originally Posted by emersushea  First off, sorry for the length and the spelling/grammar errors...its been a long night.
I work nights on a busy 33-bed telemetry floor at an inner-city nonprofit hospital. I am a new grad and have been on this floor for 1 year and 4 months and I just finished training for charge. Our administrators have been making a big push to consider our floor a CICU step-down unit (but so far without the national certification). When I began working on this floor I had 4-5 patients during nights. There has since been a high turnover of staff, many RN's are moving to CCU/ICU and I find myself some nights being the most senior person on the floor. We are in a budget crunch and now are staffed 1:6 at nights with 2 CNAs and 2 monitor techs. We are accepting more complex pts, more confused/total cares and pts with gtts we've never worked with. Ok I apologize regarding the following text if it makes little-to-no sense...I would just like your opinion on the acuity of my pts this shift. how many do you take and whats your acuity? Do you think I am crazy for thinking this is too much?
Tonight I started with 5 pts and then got an ICU transfer for a total of 6.
Pt1- chf exasc, leg ulcer, chest pain (frequently on the call light for pain meds, random tasks...one of "the needy types" as horrible as that sounds.
Pt2-my icu transfer, anemic h/h (7and 21), here with SOB/CP and CHF exas) on an insulin gtt (our protocol states chemsticks q 1 hr) and just finished her 1st of 3units RBCs when arrived on the floor. MD did not order lasix between units Paged MD, did not hear back. Pt initially, stable until 15 minutes into 2nd unit of blood, then her temp spiked, o2 sats down to 80s on 6Lo2, lungs increasingly coarse. I stopped blood called MD, and demanded lasix, benadryl and that she be transfered back to unit
Pt3- chf exasc on a dobutamine gtt going at 7.5mcg/kg/ (our unit protocol states we can't take dobu >5 mcgs but CCU/ICU full and pt "stable" so MD allowed pt on my unit)
Pt4- heparin gtt and morphine PCA, s/p fem-pop and then an emergency thrombectomy...most likely going to lose her leg...dealing with low BP/urine output and tachycardia as well as pain thru HS... poss shock? should have been sent to CCU/ICU but only 1 bed left in each reserved for codes
Pt 5 32 y/o with CP, frequent requests for dilaudid, trops (-), ct abd, lungs and angio (-)
Pt 6 another young pt with CP, turns out was gastroparesis...my only pt that was low acuity except for the frequent requests for $ from her husband spending the night
What types of gtts and what pts do you see? We used to take a limited # of gtts (amio,cardizem, dobutamine, dopamine, insulin, heparin and protonix) and now we are getting alcohol gtts, lasix gtts, isuprel, higher rates of dobutamine) and pts who require q 30 min vitals, bed alarms, turns q 2 hrs, and more and more confused people. To top this all off our staff is almost entirely new grads at nights who need a lot of assistance. Is this what its like on your floors or am I crazy for feeling overwhelmed? Thanks for the input.
I work on an ICU sister unit/ step down unit. We only do heparin drips d/t a heparin protocol that's in place. We do cardizem drips, but only if it is a set drip that doesn't have to be titrated. Any other drips that require titration, frequent vs, are put in the unit where the ratio is 1:2. We have 5 to 6 patients each, and one CNA, and if we're lucky, a tele tech. I refuse to take any more than 6 patients. We have an acuity system which is supposed to correlate to the nurse's expertise level, which is how they "get away" with giving you 4 "high" and 2 "medium" acuity patients. The situation you describe was awful, and I'm sorry that you were exposed to that kind of mismanagement. I hope your situation improves quickly or I would be inclined to find another position. There are times I want to leave and not let the door hit me in the backside as I leave and our floor is nowhere near the disaster you described. And get this, our hospital just received Magnet status. Be safe, Be happy!!!
 | | Advertisement Sponsored Links | | | | No. 12 |
Mar 11, 2009, 04:52 AM
 Re: Is this too much or am I crazy...what are your units like?
I work on a 25 bed tele/oncology unit. Ideal staffing for us is 5:1 with a charge nurse and two techs. However, due to cutbacks on OT, we've been hit a lot harder. The other night we had nineteen patients total with three floor nurses, a charge nurse, and one tech. I'm surprised I still have a butt left, because it sure felt like I ran it off that night! The bed coordinators have been pushing for us to go to 7:1 at night, but our charge nurses flatly refuse. Our admin has also been refusing to put our ED on diversion, so we've been getting patients from the ED who have step-down orders that are crossed out and changed to tele just to get them a bed. And no monitor techs.
We take all kinds of drips, but we do not titrate up, just down. Nitro, lasix, natrecor, dopamine, dobutamine, insulin, amiodarone, cardizem, heparin, etc. Plus we hang chemo. And unfortunately our telemons are not compatible with our tele system, so instead of having the vitals show up on the tele monitors at the nurses station, you have to walk in the room to check them. And that doesn't even take into the mix the number of patients we have who are on IVP lopressor, labetalol, hydralazine, etc. for BP control...it's not unusual for us to get patients who are having MI's on repeated beta blocker pushes or those with sky-high BP's that are getting IVP meds every hour or two.
Some nights it's a recipe for disaster, but we all work together well. If we didn't have the staff that we do, it would be horrible. I shudder to think what would happen if some of our stronger staff left; we usually have one or two weak nurses on each shift (some of them b/c they just can't manage, some of them b/c they are new grads who are still not quite there yet as far as experience goes); but the stronger nurses are there to fall back on, and we usually don't mind.
| | No. 13 |
Mar 11, 2009, 05:01 AM
Re: Is this too much or am I crazy...what are your units like?
Ounds really busy. Are all the pts on your floor that busy with drips and major problems? If not, I suggest to share the wealth with your co-workers and divide up the really rough pts.
And if you still don't like it, try something else. There's lots of good places to work out there.
Good luck
| | No. 14 |
Mar 12, 2009, 01:29 PM
Re: Is this too much or am I crazy...what are your units like?
Too much.
| | No. 15 |
Sep 09, 2009, 05:54 PM
Re: Is this too much or am I crazy...what are your units like?
That sounds awful! But sadly many nurses experience similar situations.
I am only 1.5 years into my nursing career, but from what I've experienced I am even more motivated to do something to stop this from being accepted as 'just part of the job.'
From what I remember, there were 400 or so applicants for nursing school and only 160 available spots! There is the stem of our current crisis/shortage.
We need to start looking at the bigger picture. Don't just say you will go where you have better working conditions. Instead, think of ways you can best contribute to help solving this problem!
Whether it be becoming a clinical instructor or going back to school to eventually teach nursing...
| | No. 17 |
Sep 15, 2009, 12:10 PM
Updated
Sep 15, 2009 at 12:21 PM by Franciscangypsy
Re: Is this too much or am I crazy...what are your units like?
We get amio,cardizem, dobutamine, dopamine, heparin, and protonix, as well, but we also get Integrilin. I believe we also give Tikosyn as a drip every once in a while. Oh, and EVERYONE has Heparin that needs to be titrated up or down depending on APTT. At least it seems like everyone. 
I actually don't know of a drip we DON'T take. I'm new to Telemetry, though, so I just might not know yet.
Wow; you guys who have 1:4 or 1:5 ratio are lucky... or just have a REALLY hard patient load. 1:6 for dayshift here and 1:7 for nightshift. Haven't gotten off orientation yet and a little nervous about starting up without a preceptor watching my tail... AND with a full load. I'm on nights, thank goodness. Dayshift is too crazy for me. Having multiple post caths coming in at once AND a pt on Integrilin is NUTS
I'm also surprised that so many people are saying that their floor doesn't take anyone with q15 or q30 min vitals. Does that mean that y'all don't take people getting infusions or post cath pts? Or post pacer? Where do they go? Or did I just misunderstand?  | | No. 18 |
Sep 15, 2009, 05:50 PM
Re: Is this too much or am I crazy...what are your units like?
Anybody who is on an insulin drip needs to be in an ICU, period. Q1h sugars get hard to keep up with even there; when you have 5 other patients to think about then either sugars will get missed or some other patient care will get missed.
The patient who still needed a lot of inotropic support with dobutamine needed to be in an ICU; you should never have to take titratable drips on the floor, it's just plain not safe.
And the lady with low urine output in possible shock? She at the very least needed to be part of a decreased ratio. Good candidate for an ICU as her vital signs seemed to be deteriorating.
That was a very unsafe patient load, and it's not right if the nurses on your floor routinely have loads like that.
| | No. 19 |
Sep 15, 2009, 09:24 PM
Re: Is this too much or am I crazy...what are your units like?
I'm surprised by how many people work on floors who don't have to get insulin drips, that would be great. I worked on a medical floor before and we got a ton of insulin drips, we have a pathway and based on their labs if they are DKA then they go to the unit, otherwise they can do the insulin drip on any other floor.
I work on a 45 bed cardiac unit. We get post cath, post pacer, etc along with drips that we can titrate. We do heparin, cardizem, nitro, integrilin, lasix, etc. On nights and days we have the same ratios, you usually start out with 3 and get an admission or start with 4 patients. On a very rare occasion we will get a 5th patient.
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That does not make it better. I have left areas where this type of staffing have been the norm. With the units being so full, I can understand why the patients were on your floor. But at the same time, the load that you mentioned should have been covered by at least 2 nurses. 
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