I started a new job recently, and I come with several years of experience in CVICU nursing. I feel pretty confident in my ability to safely and effectively care for the sickest of the sick.

That said, the way my new job does things makes me incredibly uncomfortable. I had a fresh-op patient who was on supratherapeutic vasoactive meds, on an IABP and his index was 1.8-2. The nurse who was "precepting" me told me that I should do q15minute vitals x's 8, q30 x's 4 and then q1h. I declined. Politely. ish.

She also tried to hang 30 mmol of Kphos while the patient was getting 40 of KCL. She has several years of CV experience in other hospitals so I was surprised to see such a difference in what we thought was appropriate. I tried to find hospital policies to back me up or prove me wrong, but I couldn't find anything.

I have some intention of talking to my manager if I this seems like normal behavior, or possibly trying to find a new job, or just getting boatloads of malpractice insurance. However, I don't want to cause a ruckus if this level of care is...acceptable elsewhere.

So, is this considered appropriate and safe elsewhere? Am I being a know-it-all since I've had a few jobs before, and "the way we did it there is the only way to do things"?

What is your rationale for declining to chart vitals per your preceptor? Were you doing them more frequently or less frequently? Just curious.

Sorry, I could have been more clear.

I continued to chart q15 minutes. My rationale was that q1hour vitals (esp. BP) aren't really appropriate in a patient on a lot of support.

What do your unit protocols/policies say?

I looked up the protocols and policies and there really isn't anything specific. "Typical" care of post-op patients is VS q15min x's 8, q30min x's 4 and then q1h. That said, I've always worked places where we would do VS more frequently if they were on gtts we were titrating, or unstable.

It sounds like more of a guideline for the post op patients, but if the patient is that unstable and requires multiple pressors than they probably do need more frequent VS. I think it depends on the patient on how frequent they need vital signs, except if there is a protocol or a standard for post ops.

My standard practice (and the policy at my current facility) is to document vitals Q15mins any time I'm titrating pressors. If they've been on low dose pressors (like renal dosing dopamine, for example) and there hasn't been any titration for 2 hours, then we can go to 30 mins. If there is still no titration for another hour, then to Q1hr. The above, however, really only applies to MICU, though. I always do Q15mins on post-ops/hearts until the vasoactives are off, but of course we get art lines in those guys, anyway.

i guess i'm kind of wondering what you hope to accomplish here -- patient safety? "proving" to your preceptor that you know best? just doing your own thing?

i don't see anything wrong with doing vital signs every 15 minutes x 8 as your preceptor suggested. after two hours, the patient is either more stable or he's not. if he's not, continue to do vitals as often as you think you need to -- without "polite-ishly" declining to do as your preceptor suggests. just do it. if he is more stable, he does have an arterial line, ecg monitoring and possibly a pa, doesn't he? if you're paying attention, you can see if there's a change in his vital signs whether or not you were writing them down every fifteen minutes. if you see a change, then by all means step up the vital signs. but i see nothing positive to be gained by arguing with your preceptor about such a mundane matter. if their hospital policy is q 15 x 8, q 30 x 4 and then q hour, you're not, as an orientee, going to change their practice.

as far as hanging both kcl and kphos -- what was the potassium? if it was approaching 2 or even heading past 3 on the way south, it might be appropriate. it also depends on how fast she was running each of them. if the patient isn't getting more than 40meq of potassium over an hour, why not? it does make it more difficult to predict what your next k+ is going to be, but you do have the resources to keep checking, don't you?

whenever you take a new job, you have to learn new standards of care, new policies, new protocols and new politics. it is never good politics to tell folks at the new job that they did it better at your old one. it's never good politics to argue with your preceptor, although clearly they're not always right and there are times when it's necessary. (when your preceptor is about to "defibrillate" artifact, for example. or when the "fentanyl" she is picking up to push is clearly labeled "phenylephrine".

i don't see anything positive to be gained by telling your manager that her staff's standards aren't up to yours, either. but you do as you need to . . . if your new colleagues decide they don't like you, it's no doubt because they're all "eating their young."

Ruby : I wanna come work with you

Ruby: Thank you, sincerely. I posted on here because I was frustrated and trying to figure out if I was being an ICU know-it-all diva or if I had legitimate safety complaints. So far, I think my answer is: a little of both.

I was concerned because the patient was very sick, the vitals were all over the place and we were frequently titratting gtts. In my past experience, all these things automatically = q15 MAPs (sometimes other VS if indicated), and potassium was never ever given more than 20 mEq/hour. Again- new place has no policies I can find, and I spent quite a bit of time later looking. I've done a very little bit of research online after originally posting on here, and have found several sources that say 40 mEq/h is alright "with physician orders" but I don't know our physicians well enough to know if they'd actually know/care about things like medication administration rates (cue story about my past job experiences here). Also at past jobs, I always kept my alarm volumes high enough to hear them if I stepped slightly outside of the room, and kept my alarm limits fairly close. At my new job, we're not supposed to change the alarm limits if we can help it (I haven't figured out why yet), and the alarm volumes are kept at 10% to promote patient rest.

That said, I am aware that "The Way We Did Things" is not the only way to do things. My knee jerk reaction of course is to go back to my past experiences when I'm working- if I didn't I would be a slobbering idiot. When someone is telling me to do things that seem unsafe, I typically get concerned (and so do you- if you had a new job and your preceptor told you it was unit policy to jump of a bridge, would you do it?). But then I have to rethink what is actually un/safe vs. just standard operating procedure in my past life? So thank you for giving me honest feedback. I absolutely promise not to come here and whine that they're "eating me" or giving me crappy assignments (I expect it and know that I have to prove I'm not a slobbering idiot) or a crappy schedule (ha- joke's on them! I don't really care what I work and love overtime- bwhahaha).

Hi. I have been in my current job for 5 years now. I have always said my old place did things better. It's hard when it's true!

But I have stayed here, and I can draw on that past experience to add to my current practice. There are many ways to get the same result in critical care. The profession would not move forward if we all did it the same, if we hadn't learned something from elsewhere.

It took about 2 years to get settled into my new job. And don't worry about what others think about you saying it was done differently elsewhere.

A nurse with experience is a bonus these days. And it is interesting. Stick with it!

VS q 15 x 8 is two hours worth of frequent Vitals. After 2 hours, I would then determine whether I needed to continue q 15 or go on with the protocol of q 30 mins. I always chart VS before and after titrating pressors or inotropes. So you would be doing them more frequently if you were continuing to titrate. Is it possible that your preceptor was just pointing out their standard post-op VS? Also, k-phos has an extended infusion time of 6 hours so I am not sure that I would wait an entire 6 hours to infuse the Kcl. This, of course, depends on the patient's K level. Doing things differently doesn't necessarily mean that they are being done wrong.