Floor nursing vs ICU nursing

General E. Speaking, RN, RN · Jul 30, 2010

I have only been in ICU for two months. I used to work MedSurg and Tele. There were days on Tele that were just aweful. My worst day that I can remember went something like this:

5 patients.

#1 pt has hemaglobin of 7- needs 2 units PRBCs. Pt is confused and cannot sign conset requiring me to dig through chart, call, get phone consent for blood.

#2 pt has K+ of 2.9 needing K riders. Frequent PVCs on monitor. IV immediately starts burning after infusion starts (despite having called pharmacy to mix K+ w/ Lidocaine in 500ml -per policy). They have no central line and of, course, NO veins.

#3 pt has fractured her hip and is confused. She is waiting for ORIF and is in Bucks traction and is incontinent- no foley ordered despite begging. Keeps asking for water every 5 minutes because she cannot remember anything. Told her (nicely, of course) about 75 times "you are in the hospital because you broke your hip"

#4 pt is sickle cell crisis and pain is not controlled despite mega amounts of narcotics

#5 pt is s/p TURP and is clogging up because of clots. I unclog the clots w/ aggressive irrigation. Running the CBI as fast as I can but hospital only has 2,000ml foley bags in stock so by the time I can get back into the room, the foley bag looks like a big fat cherry that is about to explode because it needs to be emptied.

Busiest days in ICU so far went somthing like this:

Overdose 30 yo pt on a vent w/ Levophed, Propofol, Bicarb, NS boluses, con't Protonix, K runs, multiple antibiotics, Albumin. Troponins elevated- cocaine induced MI? Thinking sepsis now though w/ rhabdo... no urine output X 8 hrs, sky hi WBCs. Doc put in a central line, Quinton and started CVP monitoring.

Had a patient on 7 IVs. Rocuronium, ativan, fentanyl, NS x 2, Vasopressin, Levophed. She also had an art line, was vented (of course) and had chest tubes, feeding tube, tesseo for HD.... We started the Rocuronium gtt on my shift so I got to practice the Train of Four with the (what I call) the tazer. I switched out the flush bag for the art line. We changed all the tubings and hooked up a manifold for the infusions. This poor patient had the most subcutaneous emphysema I have ever seen. It seemed to grow as I watched. Her neck and face were huge. Issues w/ her trach and air escape plus chest tubes leaking. Got to practice lots of blood draws from her art line. Lots of practice titrating the pressors because her bp dropped a lot during HD. Lots of tips from RT about vent setting changes related to current ABGs.

Both busy, just different kinds of busy.

aCRNAhopeful · Jul 30, 2010

Different kinds of busy yes indeed. But at least with the latter, you were able to optimize the care of a critically sick patient where as with the former, you ran back and forth hoping to god that none of the patients got hurt because you weren't able to be in the room to help them. My hats off to you though, because I would certainly not have been able to juggle that patient load on the tele floor.

RedhairedNurse, BSN, RN · Jul 31, 2010

Are there lots of deaths to deal with in ICU, that seems it would be the hardest part. I would love to work ICU, I feel like I need more of a challenge and want

to learn more than average medsurg kind of stuff. I worry about the dying part....I work in county hospital and I know there are lots of ICU pts that just don't pull thru. How do you handle it?

General E. Speaking, RN, RN · Jul 31, 2010

Are there lots of deaths to deal with in ICU, that seems it would be the hardest part. I would love to work ICU, I feel like I need more of a challenge and want
to learn more than average medsurg kind of stuff. I worry about the dying part....I work in county hospital and I know there are lots of ICU pts that just don't pull thru. How do you handle it?

Personally, I guess like every other nurse. You sorta have to have a detached attachment. I mean, you are focused on what you can do to keep your patient alive and the needs of the family. You think of the patient as a whole person and try to address all their needs. But there is an invisible barrier there that allows you to think rationally instead of totally emotionally. You give the best care possible but realize that sometimes the body wears out. I still feel sad and sometimes even cry but try to realize that I have done my best job as their nurse: treated them with dignity and respect, advocated for what's best for them, controlled their pain, and kept them as clean and as comfortable as possible.

Every now and then, tho, that "detached attachment" mentality goes out the window and you cannot help but form a strong emotional bond. Those few still haunt me.

Shanlee79 · Jul 31, 2010

Just read through this thread and I found it very valuable. I have to make a practicum placement choice for school this fall. I just met with my instructor about this same topic, as I have been having difficulty trying to find an area I think I might enjoy.

What tends to bother me so far on the floor is trying to get the important things done, while juggling patients of varied critical status, with varied requests. I had one critical patient this week and two others who were stable but constantly calling me for blankets or icecream cups or simply a chit chat. I would love to have the time to do these things but we don't and not only that, but I find myself more comfortable and enjoy devoting my time and energy with the more critical pt. I like to be in the know how and I find on the floor, no matter how on-top I am with orders, I am always still two-steps behind and when you really need a doc, good luck.

My instructor suggested the ICU/PICU, she joked by calling me her 'l'il control freak'. I never considered this area before but now I am re-thinking it. I wouldn't say I am a control freak, as I can roll with the punches too, but I guess I do enjoy knowing as much as I can about a situation and staying ontop of things.

BellaInBlueScrubsRN · Aug 1, 2010

Shanlee79: Before I graduated, I did an internship program. I did ICU as well as general med surg. Both completely different and challenging in the different ways. I work ICU now. It's challenging because there is so much to know. But you have to know it for 2 patients. Medsurg is hard because you have to know it for 5 patients. And the doctors expect you to know EVERYTHING about all those pts still. Its hard!

ICU for a practicum you could get a taste while you are still in school. Learn a lot of patho! But maybe I'm just biased :)

Shanlee79 · Aug 1, 2010

Thanks Bella for your input. I think I would be up for the challenge and I hope shadowing will re-inforce what I am looking for. My CEF says my concerns could be b/c I am a student but I don't think it is an issue with me being new and lacking confidence. I am a mature student in my 30's, who has no problems approaching other health team members. It's the lack of their availability and my hands being tied that already gets to me. My best classes were health assessment, pharmacology and maintenance(medicine/patho), so hopefully I am heading the right way!

JustinTRN · Aug 2, 2010

Floor nursing is much harder and nurses know it. You just use your brain more in critical care. No pun intended. We have to have acute time management skills, clinical reasoning, and critical thinking skills. Many floor nursing jobs felt like slave labor to me. Go fetch this and that. I need this and that....for 10 patients. I felt like a glorified waiter.

Shanlee79 · Aug 2, 2010

Floor nursing is much harder and nurses know it. You just use your brain more in critical care. No pun intended. We have to have acute time management skills, clinical reasoning, and critical thinking skills. Many floor nursing jobs felt like slave labor to me. Go fetch this and that. I need this and that....for 10 patients. I felt like a glorified waiter.

LOL. Too funny, You're right on the money. I was a waitress for nearly a decade and some shifts I feel no different then my days at the restaurant. I think even by habit, sometimes when they're eating their meal trays, I do a food quality check after their first few bites. haha.

BellaInBlueScrubsRN · Aug 3, 2010

ICU nursing you have to make split, quick decisions sometimes. When your pt goes downhill, they can go downhill quick; Whereas pts on the floor are more stable. There is a lot more autonomy I think back in the ICU. Something emergent needs done, often you do it then call a doc later. Last month I had back-to-back pt's one weekend that I was running my bottom off trying to save em and they both ended up coding and dying. (fighting with the doc on the phone when I said the pt was coding again, he thought I was talking about where we had coded him earlier in the AM. Had to repeat myself a few times before he got that we were doing round 3 of coding!) Then the third day I was in a code for someone else. When someone is going into constant VTach- with or without a pulse, that was last week. Starting CVVHD AND rotoprone bed on same pt(I didn't even know you could do both at once)!. That was last month. That's busy! I never see my 2 paid breaks, and usually eat in 10 minutes. 20 if its a great day. Floor nursing I took a 15 min breakfast and skipping a 40 min lunch? No way!

General E. Speaking, RN, RN · Aug 5, 2010

ICU nursing you have to make split, quick decisions sometimes. When your pt goes downhill, they can go downhill quick; Whereas pts on the floor are more stable. There is a lot more autonomy I think back in the ICU. Something emergent needs done, often you do it then call a doc later. Last month I had back-to-back pt's one weekend that I was running my bottom off trying to save em and they both ended up coding and dying. (fighting with the doc on the phone when I said the pt was coding again, he thought I was talking about where we had coded him earlier in the AM. Had to repeat myself a few times before he got that we were doing round 3 of coding!) Then the third day I was in a code for someone else. When someone is going into constant VTach- with or without a pulse, that was last week. Starting CVVHD AND rotoprone bed on same pt(I didn't even know you could do both at once)!. That was last month. That's busy! I never see my 2 paid breaks, and usually eat in 10 minutes. 20 if its a great day. Floor nursing I took a 15 min breakfast and skipping a 40 min lunch? No way!

I'm drained just reading your post!

BellaInBlueScrubsRN · Aug 5, 2010

LOL, my bad! My point was that they are hard in different ways! Honestly, I did a bit of floor nursing, but mainly ICU. 5/6/7 patients does scare me! Ugh. I don't think I would wanna go back to floor nursing, bless their hearts that do.

I just hate hearing that we just have 2 patients.