I work a weekend shift - Sat night and Sun night. I am an new grad and have been working for 5 months now. My patient load is 7 (usually I start with 6 and get an admit in the middle of the night). I work a trauma floor and there is a lot going on. This past weekend my 7 patients broke down like this -
1. PCA pump and orders for q1h dilaudid (which he called for every hour), NGT to wall suction, O2 per NC, abdominal incision with 2 penrose drains, central line with nurse drawing AM labs, and contact isolation.
2. Trach patient, contact isolation, quadrapeligic needing turned q2h, called q2h for pain meds, central line with nurse drawing AM labs.
3. Contact isolation, sterile dressing change, called q2h for pain meds.
4. NGT with TF, uncontrolled pain and called q1h for pain meds, central line with nurse drawing AM labs.
5. S/P open appy, Chest pain with Hx of MI, NPO but was trying to drink water anyway, central line with nurse drawing AM labs.
6. PCA pump, not much going on with patient other than recording pca med usage every 2 hrs.
7. S/P abdominal surgery, patient called for pain meds q2h. Not much going on other than that.
This is all in addition to giving scheduled meds and hanging IV fluids.
I was totally overwhelmed on Sat night, mainly because of the 5 AM lab draws, 3 contact isolations, and 3 PCA pumps (which have to be recorded every 2 hrs), and running all the PRN meds (i ran 24 PRN meds Saturday night). I talked with my supervisor and told her that was too much and I was overwhelmed. I requested that I not have all these patients again on Sunday night and that I would feel comfortable taking half of them. When I came in on Sunday I had every one of them again. She said "it'll be easier tonight because you already know them". Well it was not any easier at all. I ran 20 PRN meds sunday night - I guess she interprets that as easier??? Anyway, another graduate nurse that had a good patient load that was managable on Saturday night had half of his taken away and he got new patients. (note, his previous patient had not been discharged, she just changed his patients) Why couldn't she have changed MY patient load? We do have 2 techs - but they stay busy with their 19 patients each and can't really help much!!! I use my brain to manage my time. And on Sunday I decided to write out when I began a task and ended the task (medroom to exit pt room). I figured it up after my shift was over that I spent and average of 53 minutes an hour performing tasks and a total of 7 minutes charting. IS THIS NORMAL?????
Okay, I'm venting and my purpose is to find out if this in a "normal" patient load. This is the usual on the floor I work and I am thinking when my year contract is up I will be looking for something different.
Nov 13, '07
Sounds like a crappy shift-I don't like that you had so many surgical pts AND isolation pts. But I guess it happens. We generally don't like to mix them together.
(and for the pts calling you every hour-I'd be calling the dr just as often to change/increase/improve thier pain meds.)
Nov 13, '07
I'm a new grad, but in the NICU. That seems very busy to me too. I was wondering why some of these patients are not on a PCA, or need their PCA meds increased if they are asking for their PRN pain meds on the hour. Sorry, but I don't know if that's a "normal" load for your specialty. Does the night shift get more patients than the day shift? Do you have other coworkers you can talk to who have worked at other places and can compare? Good luck and kudos on making it through that weekend!
Nov 13, '07
Unfortunately these patients were on PCA pumps. But they still allow them to call for pain meds for break through pain. One patient refused to use his PCA pump regularly because he could only get 0.2 mg dilaudid every 6 minutes and he wanted the full 2 mg every hour instead. Ahhhhh! I tried to explain to him that he was not getting "more" by having me push his meds. But he got upset and said "I'm not an elephant that you can train to push a button every 6 minutes!" He wasn't happy....at all.
Let me explain my patient load without sounding too judgemental. On our floor we get a lot of trauma patients - mainly gunshot wounds. These people are usually shot because of some type of criminal/gang related activity. They seem to have built up a tolerance to the medications and require or just want more. One night a patient was scheduled 12 mg morphine every 2 hrs. NOT PRN - SCHEDULED! She was out of it and did not need that much that often. Luckily, it was not my patient. But the nurse that did care for her refused to give her anymore morphine when she found her on the toilet passed out. And the patient complained on the nurse the following day for not giving her the morphine.
Here I go again! LOL. I know one day I will sit back and say man, I remember when nursing kicked my butt! But right now, I'm just disgusted.
Nov 13, '07
LOL who are these people telling patients on PCA pumps that they can get additional PRN pain medications for "breakthrough pain" and tell them how often they can get it! I would go crazy with that many prn pain medications!
Nov 13, '07
Oooh I am sorry that happened to you!
I'm a new grad in the ED, and I'm starting to think that this is just a change in the patient culture...
Patients seem to think that they should be medicated before they have even been seen by a doctor, and that the nurse is "at their service."
Don't get me wrong, I think pain control is important and a necessity... but the line never gets drawn. Whether that is because the MD is unwilling to stand up to the patient, I can't say. All I know is that it feels like we are perpetuating the cycle... the patient gets aggressive, demands medication, the nurse responds by contacting the MD, and the patient gets what they want.
This is especially frustrating in those situations where you can SEE the patient is overmedicated, or you can deduce from their VS (not tachycardic, BP normal to low, warm and dry skin, normal respirations) that they are likely not in a huge amnt of pain.
What does everyone else think?
Nov 14, '07
That does sound like a heavy load.
Nov 14, '07
It's heavy and it could have been solved by having PCA's with basal dosing along with the demand dosing- to heck with prn pushes that the RN has to do- that defeats the purpose of a PCA.
Nov 14, '07
Great point, Canoehead. I work in peds (yeah, everybody alredy knows that) and we only use PCA for those patients who are of a cognitive level to understand it. If we see a parent pushing the button, they're done and put on a continuous infusion. Basically, any child under about 8 or 9 years of age will have a contiuous infusion that is wenaed to some other form of analgesia as permitted. Our older kids who may have severe pain issues will have a background rate and a PCA bolus dose programmed. And our pain service staff is available around the clock to make adjustments to the plan.
Nov 14, '07
Im in a rehab setting and my usual patient ratio is 5-6. Occasionally it will go to 7 cause of a new admit. Maybe a feeding tube and an o2 person. But nothing compared to that. I believe the ration should be lower cause of the heavy workload. Too much patients with alot of workload involved could be a disruption in your concentration when you have brain overload trying to get things done.
Nov 15, '07
Thanks everyone for your input. Being a new nurse I sometimes think that I am over-reacting. But this is a usual patient load for me, and all the other nurses on my unit. Needless to say, our floor has a high turn over rate. Those that have been there a year are considered long timers. You would think the clinical manager would see there is a problem by this. But I guess all she sees is what the day shift endures, but they only have 5 patients max....and because of procedures during the day there is usually one patient per nurse off the floor leaving them with 4 each. It scares me though, I'm afraid I'm gonna make a mistake because I feel so rushed, so demanded by the patients, and the fact that we are evaluated by our level of customer service. We are expected to answer the call light and be in the patient's room immediately. I agree this should be a standard! But when you have so much going on it isn't possible to be in a patients room immediately. Then the patient complains and the nurse gets into trouble.
I have taken some time to think about it and I have began looking for something different. I worked way to hard to earn my license to let this kind of pressure cause me to make a mistake and have it taken away. I will finish my committment and follow through until my contract is up, but then I'm out of there.
Nov 15, '07
Good for you for looking at other options. I am a new grad on a cardiac/med unit. During the day shift, the nurses have 5-6 patients. On my shift (3-11pm) we get 6 patients, and the night shift gets 7pts most nights. Having worked all these shifts here (I will occasionally fill in or help out when the unit is short), I can see how these caseloads differ from shift to shift. Usually 7am to 3pm shift is the busiest, so the pt load is less, but if you have a tough assignment, it does not make a difference when you work. I have had night shifts when I have had 7 pts and I was bored. I have had 3-11pm shifts when I was lucky enough to have only 4 pts, but was there till 2am charting and playing catch up. And don't let anyone ever tell you that night shift (11pm-7am)is easy! This is when the "sundowners" come out to play, and the pt will code on you in a second! Let alone that call to the doc in the wee hours of the night, with a concern, and getting grief from them for waking them up!
The caseload is tough no matter what shift you work, but if you work on a stepdown unit, or ICU, 7 pts is WAY too much!
I had a load tonight I almost couldnt handle!
6 pts: 2 pts with AMS and high fall risks, one of which was combative. Said combative pt scratched me at start of shift and drew blood, so I had to do the employee exposure ppwk and bloodwork, etc. Threw my whole night off. Another pt who was having intractable pain that only had tylenol ordered, but I had to wait to talk to the doc, since he was in ICU on a code (I understood, the pt didn't!), and got a pt from PCU with an open abd wound with a specialized dressing I have never seen with orders for Q2hr dressing changes! (The day nurse had taken report, and never told me about this). We don't do Q2hr anything on my unit. When the pt was transferred, the RN left so fast that I didn't even see her face, let alone have time to ask her about the dressing! I went to my clin II who immediately called PCU and the PCS to let them know what was happening. Pcu got the order for dressing changes changed to PRN, and the PCU clinII came down to our unit to show me what to do, which was really nice of her, since she stayed past her shift to teach me.
What a crazy night! But I have also had nights with 6 pts when I was wishing for the book I was reading at home, so it depends on the pts.
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