RN-PA

I'm locked into a "pattern", certain days I work every week. It doesn't allow for much flexibility, but I can make plans 10 years in advance. :)

I work part-time on a med-surg unit and receive pay for sick days and vacation days. I accrue the time very slowly, regardless of the number of hours I work beyond my 5 days per pay period (2 weeks). I get around 76 hours of paid vacation which is close to 9.5 days off/year. And I accrue a little less than 3 hours vacation time off per 2-week pay period. We are not allowed to take a day off unless there is enough paid vacation time accrued, so if I need a day off in mid-May and have only 8 hours of vacation pay to cover it, I can't take a day off in early June if I need it because the next 8 hours won't accrue until sometime in July. Management will let you have the day off if you pick up another day during that pay period. It has something to do with working your scheduled shifts because of receiving a pension. My problem is that if I waited for all my vacation time to accrue, I'd have to take vacations in December when I want and need to go in September. Do your units have a system like this? If I haven't lost everyone with all the above confusion, I also was wondering how your management deals with time off? We are allowed to have one person on vacation per shift. You send in your vacation request to the scheduler at least a month in advance, and if no one else has requested those days, they are granted to you, and the scheduler will get a replacement for you. But, if someone has already been granted the days off that you're requesting, you have to find your own coverage. Working 3-11, we also have 12 hour people who overlap our shift and we may need to find coverage on a requested day off for just 4 hours-- 3p-7p or 7p-11p. This is all so maddening because we already work every other holiday and every other weekend, and then we have to go through this hassle to get vacation time, and often must find our own coverage to boot. How are vacation times handled where you work?

I don't know how you're getting any of your own work done since you're doing much of what our PCT's are doing on my med-surg unit. I have 5-6 patients and the two PCTs have 12, sometimes 14 patients apiece if we're full. They start our 3-11 shift getting vital signs, and then pass out fresh water if they can. The nurses give them report on their assigned patients as soon as we can after we receive our report. (PCT's are also supposed to get report from the previous shift's PCT, and we compare notes and update each other in our nurse to PCT report.) They get Accuchecks, q1h post-op VS when we have them, answer callbells, help Pts onto bedpans or bedside commodes, do P.M. care, incontinence care, feed patients, empty NG tubes, foleys, JP's etc. and chart their own I&O's (including the Pt's IV intake we've written on a form) in the computer along with any other documentation specific to PCT's. PCT's are also supposed to ready rooms for new patients (admissions and post-ops) including gathering hygiene supplies, weighing the pt. when they arrive, completing a belongings list, and getting vital signs. The nurses also do all of the above if a PCT isn't available-- we try to work as a team. I just get mad when I'm running to get fresh water or clean a room when a PCT is frequently sitting at the desk chatting or on the phone. Doesn't happen too much though since one of us will ask for help, even if that PCT has a different team.

I always tell my patients to take a deep breath right before I jab the needle in them. Then as I'm injecting the med, I tell them to breathe out. If I'm giving an IM in the buttocks, I add to the deep breath: "wiggle your toes!"

#1- Direct admit LOL: Exacerbation COPD. #2- POD #2, prostatectomy: progressing well. #3- POD #2, total vag hyster with bladder sling: better urine output and pain management today. #4- POD #5, sigmoid resection, NPO-- good bowel sounds and flatus. Wants FOOD! #5- 40-ish male, renal calculi. Severe pain x 1. #6- S/P Septoplasty. Changing own drip pads! -------------------------------------------- It's interesting to try to reduce 9-plus hours of running like a crazed pinball machine into just 50 words. The above is just the bare-bones of a 3-11 shift where I didn't have time to sit down and chart on a computer until after 10:30 and left after midnight. It's also been interesting on our mixed med-surg unit that I've had so many post-op patients lately. Seems like I've cared for mostly medical patients for a while, and with all the nursing homes and retirement communities in my area, it often feels more like a long-term-care facility than a med-SURG unit. It's been nice for a change to have the surgical patients and to witness their progress over a few days.

Barely out of report and hand-irrigating 3-way Foley with CBI for many clots; repeat numerous times over next 8 hours; call doc 3 times for orders. Replace cath with another #24FR cath. Still clotting frequently. CT scan results = probably cancer, OR in a.m. Five other patients receive minimal care.

I wrote about this on Allnurses a while ago, but I still have to say one of my best moments in Med Surg came about as a result of caring for a young female patient who was admitted with a kidney infection. She returned to our unit six months later and asked for me during one of the busiest times in the shift. I hated to stop what I was doing, but grudgingly came out to the main desk to meet with her. When I saw her, she said, "You probably don't remember me, [i didn't] but you were my nurse when I was in with a kidney infection. You gave me such good care [and she mentioned some of the things I'd done for her] that I've decided that I'm going to become a nurse." Well, you could've knocked me over with a feather. I hugged her and we chatted a little more, and I returned to my patient care so happy and uplifted, I don't think my feet touched the floor the rest of the shift. She wrote a letter to my manager telling her everything I had done for her and her decision to go into nursing as well. In the early months, I did as much as I could to mentor her, but we slowly drifted apart. It's been a couple of years now and we don't stay in touch as much as we used to, but she continues to get her nursing prerequisites completed at a Community College and is working as a nurses' aide at a hospital nearby.

I'm sorry, but that's just crazy that your hospital expects you to float to med-surg! As a med-surg nurse, I wouldn't feel the least bit comfortable-- or safe!-- if I was pulled to L&D and asked to do all that you've been trained extensively to do. In my opinion, everything's a specialty in nursing these days. Yes, we were all trained to do med-surg in school, but managing the variety and number of patients we have takes a long time to feel comfortable and competent. Without a decent orientation to the med-surg floor, I don't think it's safe to ask nurses from L&D to take a full assignment. When an ICU nurse is pulled to our med-surg unit, they're only assigned 4 patients-- max. In the past, when L&D were rarely pulled to our unit, they basically functioned as aides as we did when pulled to L&D. Of course we could do chart-checks and give out meds, and med-surg nursing is less specialized than L&D, but I would definitely speak with nurse educators at your hospital and find out what they recommend for you to be better prepared.

Sunday, 1445-2315 shift: 1.) S/P colon resection, new colostomy, progressing well. 2.) LOL O2-dependent, CHF- Many med questions. 3.) LOL with pneumonia. 4.) Admission: rhabdomyolysis, admitted then transferred to private room-- "R/O C Diff". 5.) LOL: 120 mg IV Lasix at 1630. U.O. 2200: 100 ml. +C Diff, multiple liquid stools, dying. 6.) Hemodyalisis, non-compliant IDDM, multiple wound care, disimpacted.

We have admission nurses and I agree with what Thunderwolf said, " I value the admit nurse greatly...almost to the point of worship." Our unit clerk kids me that I have the admission nurse on speed-dial, so I can contact her the minute I hear I'm getting an admission. I believe there are two for the whole hospital, but I don't know if they are on at the same time. They work 8 and 12-hour shifts and begin around noon, but again, not sure (I work 3-11 when many admissions are finally ready for the floors). I know they're available up to around 2330. They only do the admission basics since they stay pretty busy and in-demand. They do all the computer documentation of historical and clinical data and choose/enter an appropriate care plan, but it's up to us to personalize the care plan. They only do assessments if the nurse getting the admission is an LPN, and if the admission nurse is too busy, the RN covering the LPN must do the initial assessment. They originally were helping by checking orders and even taking them off, but not anymore. Also, they only work Monday-Friday, so we do our own admissions on the weekends. We also always do our own discharges since we know the patients best, and discharges are rarely, if ever as time-consuming as admissions. I ~~~LOVE~~~ our admission nurses! :redpinkhe :loveya: :icon_hug:

Thanks for asking what would be helpful to us med-surg nurses in a transfer report. I'm someone who likes MORE information rather than LESS, whether I'm getting report from the previous shift on our unit, or from the ED, ICU, or from wherever the patient is being transferred. Basic summary of systems and recent labs are appreciated, but only the "abnormals" are necessary. Detail things like the patient can only take meds crushed in applesauce, date of last BM, or even something like a heads-up on a family member who is demanding or a patient's psych issues are very helpful. We have 2-page patient profiles which have lots of info including their allergies, diet, history, and care plan that some nurses send before a patient is transferred and those are helpful to quickly scan. Our hospital went from verbal reports to handwritten reports a few years ago that have ranged from very detailed (RARE!) to practically nothing, where we ended up getting patients who were big surprizes. When I get a sketchy report for a transfer, I call the extension and speak to the nurse who sent it, and ask for more details. The hospital is now starting to go back to verbal reports which will be great, but we will have to make ourselves available when the calls come since it gets frustrating-- and downright maddening-- for the ED or ICU nurse to be told that the nurse is busy and will call right back, and then the nurse receiving report doesn't call back-- either intentionally or by accident. As it stands now, when we get the transfer report in the pneumatic tube, the transferring unit is allowed to bring the patient up in 5-15 minutes, so yes, there isn't much time to read, but I still like to be prepared.

We had a staff meeting yesterday where two representatives of the RRT gave an update on the RRT which I think was initiated within the past 3 months. They said that the RRT members for that shift (ours only runs from 1900-0700 at this point) are determined at the beginning of the shift in ICU and it usually consists of the one RN who only has one patient. They said that then, the nurse who responds to a call for the RRT may even end up getting the patient she/he has been dealing with on the med-surg unit if they deteriorate to the point that they need to be transferred to ICU. When I asked about bringing the RRT to either 1500-1900 or 0700-1900, the reps. said that traditionally, 0700-1900 is busier on ICU and they don't think they can spare a nurse as easily then. It's got to sometimes be a hardship on ICU when they have to absorb a third patient for a while...

I call 'em "Floor-Kisser" shifts. I get home from work, get down on my hands and knees, and kiss the floor, THANKFUL to be safe at home away from the chaos and craziness. A nice bowl of ice cream often helps, too.

WOW-- that's interesting. If I get a chance this weekend, I'll ask one of our pharmacists if IV push Protonix is in the wings for us, too. Only drawback would be that the LPN's wouldn't be able to give it and it'd be one more med we'd have to push for them. (We're getting more and more orders for IV rather than IM narcs recently.)

I frequently administer Protonix 40 mg IV (in 50 ml NSS) to patients, and when it first came out a while back, we had to change IV tubing with each Protonix piggyback we hung and it also came with its own filter. It couldn't be mixed with any solution except normal saline, so you usually would have to cap whatever primary IV was hanging, flush the iV site with 10 ml NSS before and after, administer the Protonix over 15 minutes, and throw away the tubing when finished. Well, now there's no filter needed, the IV tubing can be changed every 72 hours like other piggyback meds, but the pharmacy at my hospital still says it probably shouldn't be piggybacked into an IV containing dextrose or KCL or other IV fluid besides NSS. I asked our nurse educator to check into what the current policy is since she wasn't sure. I continue to stop whatever primary IV is infusing, and flush with 10 ml NSS before and after the Protonix. I also label the tubing with the date and that it's PROTONIX so that staff doesn't use it for an IV antibiotic, but I think I'm the only one who does that. What's the Protonix protocol in your facility?

Congratulations on becoming an RN, Shawnette! I also thought I could never work med-surg after negative experiences during clinicals, but I ended up liking it for the same reasons you do: the variety of patients and all there is to learn and experience. There are times when I think I can't work med-surg anymore when the acuity of my patients is high and I have to spread myself too thin among 6 patients, but when I think about trying any other area of nursing, med-surg keeps me coming back for the reasons mentioned.

Good question-- I have no idea and hope someone will answer. I have a friend who used to work with us as a Unit Clerk with no background or training in the medical field and she's now a Unit Clerk/Monitor Tech at another hospital. I can't really imagine how Monitor Techs do their jobs and what it must be like to be staring at a bunch of screens for hours.

You and some others have mentioned monitor techs, but as far as I've heard, we won't be using them. It seems like it'll be tough to keep an eye/ear on monitors while I'm running around (as usual) caring for a variety of patients. Also, you're very fortunate to have such great resources for chemo. Unfortunately, we don't use charge nurses and on 3-11 shift which I work, any nurse educators are often not available. We have a few nurses who are already experienced in chemo, but they all work part-time and you never know if you'll be working with them or not. *SIGH* :stone As I think about all this and read the responses, I can feel a long letter to management starting to formulate which would voice all the concerns mentioned here.................

I'm not sure what it'll be called. It's supposed to be implemented in the next 6 months and what you quoted from my post is all I know about it so far. I know management and the committee working on computerized MAR's has considered various methods to hold our meds like either our own individual rolling cart or a "wall-a-roo" (I have no idea if this is the right word for a fold-down medication station attached to the wall in or outside the patients' room.) We got these computers on wheels when the hospital went to online documentation in 2003-- a medication cabinet with drawers was supposed to fit and eventually be added. But the computers are so big and unwieldy alone, without med drawers, that they're difficult to wheel and maneuver into small, semi-private rooms. I hope we get something like the MAK system you described. What we have right now are meds dispensed in individual, small, opaque cellophane, sealed, flat "bags" with a barcode and name of med on them, placed in one of 10 drawers in our med carts. Beyond that preparation for the future, I haven't the foggiest idea what's coming. I realize computerized meds are a safer method, but it's hard not to get caught up in stress when time-consuming procedures keep being added to our already heavy workloads. Hopefully it'll be better than I imagine.

We're taking a 3-day course at a university hospital and then taking an exam to be able to administer chemo, so it should be safe; the problem is that we don't get a lot of inpatient chemotherapy patients-- Most are going to our outpatient infusion department. We generally care for patients with the after-effects of chemo: dehydration, neutropenia, anemia, etc. in addition to our med-surg patients. My concern is as I said before: If you don't use it, you lose it. If as a part-timer you get a chemotherapy or telemetry patient very infrequently, it's not easy to remember all you've been taught unless you practice it regularly. As far as the nurse to patient ratio, management has already reduced the sister med-surg unit to a 5:1 ratio with one more aide than we have because they have a lot of isolation rooms and sometimes more of the higher acuity patients. (Trachs, occassional peritoneal dialysis, etc.) The problem lies in the staffing at the beginning of a shift. If you have been assigned 5-6 med-surg patients and an admission needs chemo or telemetry, I was told my co-workers will absorb one or two of my patients. So where is continuity and quality of care for those patients?

Administration at my hospital is planning to make us a "Universal Beds" hospital in a year or so. I work part-time on a med-surg unit, and the plans are to make more beds in the hospital telemetry-capable. On our 30-bed med-surg unit which has an oncology emphasis, we will have the capacity for 8 telemetry beds while our "sister" general med-surg unit will have an 18 bed capacity (out of 32 beds). We are all going to have to be cardiac monitor trained and ACLS certified as well as BLS certified. (On another note, I am also being sent to a mandatory 3-day course to learn chemotherapy administration the end of this year.) Administration believes that the Universal Bed concept is much better for the patients and they've found that when a patient is transferred to another unit like telemetry, at least one day is added to their length of stay, so this should save the hospital money and be less of a disturbance for the patient and family to keep them in the same bed during their hospitalization. The staff has been told that their nurse to patient ratio will be reduced from 1:6 to 1:5. But my concern is that we have a LOT of part-time nurses and I'm wondering how we can be competent let alone proficient in reading monitors (and also administering chemotherapy on our unit) when we may possibly be assigned these patients infrequently? (If you don't use it, you lose it.) I'd love to get feedback from anyone whose hospital has implemented this system or if they haven't, what you think about this concept. I would like to feel positive about all the changes, knowing that it sounds like they'll be better for the patients. But I'm feeling leary about all of this since, as a med-surg nurse, I often sort of feel like I'm a "Jack of all trades, master of none", and this is really threatening to make that feeling more pronounced. Also, I never was interested in telemetry; I just wanted to do med-surg, but it looks like those days will soon be in the past. (We're not even called med-surg anymore; we're now "Acute Care".)

Hi Anna! What Cheerfuldoer expresses above is exactly what was going through my mind as I read your post. I've never been too great about receiving criticism and when you're being oriented, your preceptor needs to sometimes criticize-- constructively, we hope-- so that you can learn. It's difficult because you're just coming from a school situation where you were most likely frequently criticized (I was!), and it's hard to continually experience the feeling that you don't measure up. Please be patient with and kind to yourself as you go through this period, and try to lower your expectations of yourself. I know it's easier said than done when you're hearing more negative than positive during your orientation. Many preceptors aren't natural encouragers OR teachers, so you have to sift through their comments and learn from what you believe is true and let go of what may not be. Even ask for some positive feedback if you feel the comments are unfairly weighted by the negative. I don't want to discourage you any further, but I often am still on a rollercoaster of emotion working med-surg 3-11 shift-- and I've been doing this for 11 years. I've often felt like a pinball as I fly through my 8 hours and I feel some evenings like I can't get it right-- can't please the patients or families; doctors get upset with me; and I'm always trying to prioritize and manage time properly. I did find that I felt better about things once I was off orientation and on my own. Nobody looking over my shoulder, scrutinizing everything I did. I was free to goof up and make some blunders, but oftentimes, I was the only one who knew about them. I'd learn from them (and beat myself up over them :) ) and move on to the next crisis. And it's okay to cry or be angry or resentful or whatever-- this is a very stressful time in your life. I would suggest that you try to have balance in your life, and surround yourself with positive experiences on your days off to counterbalance the negatives you experience at work. Do something that you do well and enjoy. Exercise to sweat out the stress. Eat as well-balanced a diet that you can. Treat yourself in ways that build yourself up-- shopping or going out to lunch with a friend or a walk out in nature-- whatever rejuvenates you so that you can keep going back to "do battle" at work. And enjoy and celebrate the triumphs and even the smallest successful steps you're making at work. We've all been there and understand what you're feeling. Med-surg is hard, and I'm not sure I could handle its demands starting out as a new grad today. You may find that 11-7 or 1900-0700 would be less stressful shifts or maybe even a different specialty. I am always challenged by and often stressed by med-surg, but I still feel like it's the best fit for me, and I hope you'll be able to say the same in the years to come. Hang in there, Anna! :kiss

We also have handwritten MAR's at my hospital, but are going computerized within the next year. I don't mind the handwritten MAR's-- they're what I've always known, but the handwriting can sometimes be pretty bad. If I run into something that could be misread, I just recopy it. I'm told that our new system will involve barcodes and it sounds pretty cumbersome/time-consuming from the little I've heard about it so far. We'll be scanning the barcode on our ID badges, scanning the barcode on each med, then scanning the patient's ID bracelet's barcode before administering a med. Anyone else out there have a system like this? I love our Pyxises, too. Great to not have to count narcs the end of every shift. The only hassle is that we have to sign a slot in a book at various times during the day which I think means that there are no Pyxis irregularities at that time. (On 3-11 shift, its 1500, 1900, and 2300.) Our managers are always on us if every time slot isn't filled in. They always seem to find a way to add more work even when something new requires less work. :stone

I love cats but can't help you with your questions, unfortunately. I would suggest doing a Google Search by typing in "Cat Questions" (which I just did) and you should probably find some sites where Vets and others can help you. Here are a couple of sites that may be helpful that were the first three that came up on Google. http://www.thepetcenter.com/exa/FAQ.htm http://cats.about.com/mpboards.htm http://www.catchat.org/forum.html Wishing you and your kitty(ies) all the best!

On a medical/surgical ward What would be a typical shift for an RN? Things I would like to know are When you arrive on duty what do you do after hand over. I work 2:45 p.m. to 11:15 p.m. (usually, much later :)) and after receiving report (or handover), I check meds. for each patient, write them down, quickly check charts, and then begin assessing patients before dinner arrives at 5:00. I also give report to the aide and get vital signs and blood sugar results from them after 4:00. What are the times of the medications. Our routine med. times are : Once daily: 0800. BID meds are 0800-1800. TID meds are 0800-1300-1800. QID are 0800-1300-1800-2200. HS meds at 2200. Q8H meds are given at 0800-1600-0000 or 0400-1200-2000. Coumadin is given at 1800, Digoxin at noon. Those are our "routine" med times, but q 24 hr IV antibiotics could be given anytime. How many patients would you be expected to look after, and what would you be expected to do for each patient? We can have 6-7 patients on all three shifts and we assess, medicate, perform wound care, teach, deal with family questions and needs, empty urinals and bedpans, ambulate patients, whatever-- pretty much what an aide does if the aide isn't available. We call doctors for problems/needs or to report new findings (labs and other results that are abnormal) We do computer documentation, but there's never time to read the chart or Progress Notes, unfortunately. Wish there was since I don't always feel I have a clear, complete picture of the person I'm caring for. Can nurses self prescribe anything? No. What time aprox are the shifts/ 12 hour shifts are most popular for the full-timers, but there are still a number of full-time 8-hour shift workers. Part-timers work 8 or 12 hour shifts and Pool or Casual nurses work 4, 8, or 12 hours, wherever the need is. Our 12 hour shifts are 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. 8 hour shifts are 7-3, 3-11, and 11-7. Hope this helps! :)