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 coorifice. 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 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.
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.
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...
I only have one thing to say. You worked too hard to get your license to be overworked and understaffed as it sounds like. Eventually something will go wrong and the docs will not take the blame. Find a better staffed place to work and save your career.
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. :icon_roll
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?
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.
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.
My first tele job was similiar. Extremely sick pts with patho and gtts (and 5:1 ratios) that would easily be in the ICU in many other hospitals. Later, I moved to an ICU at a different facility. At this hospital, the only drip on their tele floor was Heparin. The nurses in this ICU commented that the tele floor was not "progressive" and they remember all the things that they titrated when "they" were on tele.
When I first started out, I though it was a 'badge of honor' to tell all of my new grad nursing school friends about all the stuff I have seen (drips, meds, crashing pts, etc.). I felt that I was having such a better learning experience than they were (which, to some degree, I was).
As time passed, I began to realize how much the stress was waring on me. I was leaving work frustrated, barely getting through the orders of the day. Because many of the patients were sick enough to need ICU care, they took a great deal of time and energy to care for. Lunch was a joke and bathroom breaks were rare. Codes and transfers back to the ICU were a little more common than they should have been. All of this translates into a decrease in the quality of patient care. Was I teaching my new onset CHF pts about lifestyle changes? Nope, I was too busy titrating the 75 mcg/min of nitro that my HTN pt needed. Was I preparing my preop CABG pt for his postop recovery? Nope, I was too busy grabbing lidocaine (who still uses that? ) for my post code whose bag is running out and is throwing PVC's.
This stress that you experience at work carries over to all areas of your life, whether you realize it or not. I was gaining weight and becoming less healthy. I even think I started getting a little depressed. I know that I saw this with many of my co-workers.
Most importantly, in all this chaos mistakes will be made. If they are, no one will take into consideration that you had a crazy pt load - not administration, the pt or family, or the nursing board. Do not underestimate this last comment. Also, my friends who were working in better environments were making the same amount of money, because this area pays based on years of experience. Although they weren't stress free, I could tell that things were better.
Too often we rate our nursing abilities by how sick our patients are. Everyone wants to be the hero that saves the lives on the high-ratio, drip-giving, IV-pushing, code-having floor. It's great to be able to manage high acuity patients, but we also have to realize that if we only focus on that aspect of nursing care, we are doing much more harm than good for our patients.
When Mrs. Johnson is admitted for STEMI, it's a big deal. Do you think she would really trust you as her nurse if she knew that - because you've accepted a crazy work load - you may not have time to teach her about her labs, give her pain meds, or be there right away if she codes while another pt decompensates? What about John Smith, the new diabetic on the insulin gtt? Would he drive to another hospital if he knew that you probably didn't have time for his q1hr BS's? How could you with the ratios?
We are nurses, not super heroes. The economy is tough, I know. Unfortunately, you really need to move to another area. You aren't doing anyone any favors by working in (and, in a way, helping to maintain) an environment like this. These environments exist because we - as nurses - allow them to exist.
Hey, i was wondering after reading your post how things are going at your job. Are they any better or worse? Are you still there? I am a new nurse, have been on a cardiac floor where we mostly take pts post cabg, thoracic cases and amputations. some we get are overflow of medical like chf exbaration. the situation you described scared me to death. i felt overwhelmed just reading it. now all of our post surical pts come out on an insulin gtt and we do blood sugar checcks every hour. they also come out with several chest tubes. so those patients usually require more attention. we may have one on an amio gtt. but typically we on nights have 4 pts on and sometimes 5 when we r short with charge having up to 3. (bad nights) but usually we have one walky talky that is going home the next day. one post cabg. maybe a chest pain with a nitro gtt or doputatmine gtt. but never everything all at once what you had. i hope things are better for you know. it is interesting to hear what other nurses go through.
Last night was a pretty crummy night for me... split shift, first 4 hours on a medical floor w/varied acuity pt's 3 pt's and one admission, last 8 hours on my own tele floor with 6 new pt's.
Put my head in a spin for sure! :brnfrt: Charting on ten pt's.. crazy!
Normal ratio on my tele unit is 1:7 on nights, days usually 1:4 or 1:5. I've also gotten 6 pt's w/two additional admissions. We get drips galore .. cardizem w/titration parameters, of course heparin drips, usually caring for 4-6 cardiac monitored pt's during the night. It's RIDICULOUS!!!!! Then I get flack about sometimes appearing disorganized during morning report... Ya think??!!! :sstrs:
Seems this unsafe practice is all over the place, and the more ya complain to the uppers, the more wasted air there is in the world. :selfbonk:
It's all about budgets and justifying why an extra nurse was called in to help out vs putting pt safety first.
What can be done w/out jepoardizing our jobs? The more ya sqawk, the closer you are to being booted out the door.
That sounds like way too much. Consider moving to a less overworked position. Remember if you make a mistake the nursing administration will not stand behind you. They will try to put all the blame on you, and your license and not just your job might be in danger.
Been there, done that. Your unit sounds more like an IMC, which usually have 1:3 staffing ratios.
) for my post code whose bag is running out and is throwing PVC's.
mama_d, BSN, RN
1,187 Posts
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.