Is this too much or am I crazy...what are your units like?

[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 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.

[txwildflower57]

I work telemetry units at 2 hospitals. Both have recently been certified as "Stroke Units" also. We get everything!!!! If you have a good charge nurse they try to spread it around but when you have a 20 bed unit with 15 totals (300+ lbs each), 8 isolations, many drips - kinda hard. We do have the 1:6 rule ratio but that doesn't mean we will have an aid or any clerks. The hospitals I work with use some dumb staffing "Matrix" that says we can have this many licensed and non-licensed per this # of patients and it don't matter if they are of the above acuity or not - staffing isn't based on acuity just #'s. Are we working in dangerous situations - many times - especially if you have one patient you have to be in the room with a lot - you can only pray that your other 5 patients are sleeping and ok. I have heard rumors that there are better places to work but who knows.

[kool-aide, RN]

That's terrible. That needs to stop, IMMEDIATELY.

[mzbree]

It is veeeery overwhelming. I should know, as my unit is the exact same way most nights. I've seen everything from acute MIs to GI bleeds to unresponsive SVT, you name it; we've had it! The key is they are trying to make your unit a step-down unit. That's why you are seeing an increase in patient acuity level. But you have every right to be overwhelmed, and you should speak up about it. Mind you that most ICU nurses can only have a maximum of 2 patients with the acuity level that your patients have; on any other floor (well at least on ours) the max is 6 patients. I really think you should have a serious discussion with your director about how these working conditions can negatively affect patient outcome in the long run. Safety is of utmost importance (in my mind), so a nurse with only 1 and 1/4 years experience as the most experienced nurse on the shift raises a red flag.

[mzbree]

I couldn't have said it any better!

[turnforthenurse, MSN, NP]

[color=#333233]that definitely sounds like too much and is very unsafe imo, op!

[color=#333233]

[color=#333233]if a patient needs to have chemsticks q1h, they need to go to icu. we do not deal with insulin drips; icu does that and they are also placed on endotool.

[color=#333233]

[color=#333233]for gtts, we typically see cardizem, amio, heparin, lasix, octreotide, dobutamine (but usually when they're about to come off of it), ntg (but we can only titrate for chest pain, not bp), protonix and occasionally dopamine, though if they need dopamine they usually go to the unit as soon as possible. the ratio on my floor is 1:4, sometimes 1:5 if we are short-staffed or 1:6 if we are really short staffed. even with 4 patients it can be unsafe managing some of those drips. cna's vary; we usually have 2, sometimes 3 if we are full. i work on a 24 bed unit and we see all kinds of patients.

[Vespertinas]

If the OP's floor is trying to get rebranded as a step-down then they can KEEP the kind of patients they're getting but then they'll HAVE to decrease the patient load. You can't change level of care without changing the ratios. Sounds like they're halfway there.

I worked on a floor that went through a transition like that. We started taking more difficult patients to sort of get used to the acuity. Then we started getting more education. Then we changed our level of care and the ratios were clearly outlined. Then again, that job was a dream.