sunshineCCRN

darn right! :angryfire

we do not have a patient-free charge nurse and it is an issue (16 beds). our charge gives group report and briefly outlines all the patients on the unit. the whole staff listens and makes assignments out together (~15min). this is very good because when trouble happens, your coworkers know how to help you and what you need. also, no one can complain about their assignment. report is 1 on 1. we still have paper charts, so we basically go through the entire flowsheet. there is also another sheet that highlights the pt's history, what happened over the hospital stay, code status, etc. we will go over orders and do a "quick peek" if the pt is critical or has a weird drain or dressing change, etc. our kardexes are never updated and don't have the info we need on them. they might as well go in the garbage. it would be nice to have a column somewhere to write down things that are pending (ie it's PMs, and we want to make a note to ask tomorrow about a wound care consult, or maybe there are blood cultures pending that the next shift should look out for). the nurses are pretty good about these things, but it would be nice to have it written down, since you can't always trust that it will be passed on. report on 2 pts takes 30-45min.

it wasn't me, so i don't know all the facts, but yes, half the hospital administration was involved. thanks for your post, i feel a little better if i ever have to take one of his patients again. (legally, doesn't matter--just sounds like a pretty juvenile thing to do...) this doc (an attending) is, uh, well-known for sometimes being exactly that.

our open hearts have closing films just before they come to ICU. we confirm swan placement by waveforms and CXR if there is a question (usually anesthesia is right there anyway). every patient receiving a central line (IJ or SC) should have an immediate confirmation of placement--why isn't this done in the OR prior to surgery? Scary! our central lines from the cath lab or radiology are confirmed with fluoro, all others get a CXR. our nursing policy covers CXRs for line placement-no order needed. if you can draw blood and flush from all ports, and the med is stat, i would not hold a treatment. i agree with pinoy: an order would have covered her, but CXRs are always good.

We had a physician who refused to cosign a verbal order taken on night shift. This MD absolutely gave the verbal order, but since a bad outcome happened, he claimed "I never ordered that" the next day. What is the legal ramification for nurses? He gave the order, and now doesn't want to take responsibility for it.

You did a good job with him. Good thing you recognized a problem and acted--now you have a valuable experience that will probably come in handy sooner than you think!

i joined aacn. i find their Critical Care Nurse magazine really helpful. the Society of Critical Care Medicine has published guidelines for treating certain patients (end of life, neuromuscular blockade, sepsis, etc) which are the gold standard in critical care. definitely check those out. they should be free. Guidelines ps-nurses can join sccm, too.

oooh, reminds me of my psych clinicals! If they say something awful, ask (nicely, of course), "I'm sorry, what did you say?" (Makes them realize how rude they just were!) Then try to get to why they were rude: "So you're upset because [the patient isn't going to their stat CT with contrast right now]?" Then justify your actions in a non-threatening way: "Are you familiar with [our protocol for oral contrast administration]?" You kill more flies with honey, and patients lives can depend on solid communication between disciplines. BUT if they're completely out of line (cursing, threatening, making personal remarks) then, "This unit has a zero tolerance policy for disrespectful behavior, and I will not listen to this. You can come find me when you're ready to talk." In my book, every instance of workplace verbal abuse should be written up. For every one time it's documented, it's probably actually happened at least 10 times that much. No one should be treated like that.

I am completely anal at work, whether it's about washing hands or labeling/untangling IVs or having clean, disinfected counters. However, I do NOT understand why some nurses live to terrorize other nurses when the issue does not affect patient safety or quality of care. I hate messes just as much as the next person, but that's my problem and my standard for myself; I have no authority to make the last nurse feel awful, especially if they're new. I don't know any other profession where it is acceptable for coworkers to get in each others' business to the same extent as nursing does. Just my opinion.

our hospital tells our CNSs and managers that they shouldn't perform bedside care! i don't think that's ok for your manager to renew the CCRN if she didn't perfom all the requirements. why would anyone be motivated to get their CCRN if it doesn't mean anything? i guess that's a different issue, though. as a staff nurse, you can't really do anything about it beside ask her yourself and be prepared for the consequences.

I like the "mandatory" specialty nurse idea. The problem is, we have such low volume of certain patients that there's little chance for an inexperienced person to become an expert. Does your unit actually call them in on their days off when you get one of those patients? Sounds interesting....

We can give it peripherally where I work, but if I have a free port on a central line, I'll use that. Think of all those outpatient procedures that use a profpofol gtt! I doubt anyone would start a central line for those! :chuckle I always wondered about propofol's compatibility with TPN. I feel like there's too many ingredients in TPN to know if the two are truly incompatible--and it would be nearly impossible to detect a precipitate.

What kind of locked pumps allow for fentanyl and benzos? I've only seen MS, dilaudid and demerol run at a basal rate on those PCA pumps--I didn't think they made compatible containers for benzos and fentanyl.... Our regular infusion pumps have a locking mechanism, but that wouldn't stop someone from tapping the infusion bag...

Yeah, she COULD....

Thank goodness we don't have traumas. I guess it's just different in a small hospital. There have been nights when I'm the ONLY person in the house who can take a CVVH/IABP/CABG patient. So it ends up being me and a select few who are always taking patients we don't have much experience with. And oftentimes we don't have anyone else on the shift to pose a question to, unless we call the eICU...which isn't always helpful depending on their nurse's expertise. There are days when I want to say no because it could be more than I can handle, but there is no other option. Not to mention our surgeons are very difficult to work with. Some make it obvious that our hospital takes a back seat to the main one. So when a patient bleeds out at 3am....it's either "why did you let him bleed?" or "get an H/H in 3 hours and don't call me until then". Grrr.... I guess I'm starting to whine now.... where is my cheese?

Thanks for your input, jbp. I guess it's just frustrating since our unit is lacking in experienced nurses. Only 1 or 2 people per shift are fully competent enough to take any patient in the unit. It's to the point where some people say "I don't take post-op hearts" or "I'm not going to take the CVVH or IABP class". I understand where they're coming from--how can you protect your license if you are forced to take a patient you aren't comfortable with?--but that leaves the rest of us swamped and overwhelmed, too!

I went straight to ICU, and it was okay. I actually did 13 wks on med-surg after working ICU, and I was bored, frustrated, and stressed. I agree about finding a hospital with a good program. What is most important is that you are teachable AND stand up for yourself. Does that make sense? If management wants to give you 6 wks orientation, or give you a different preceptor every day, etc, and you're not ready, you need to say no. No one else will say it for you. I know it's a fine line, but it's your license, and there are people out there that love to dump on the new nurse. On the other hand, you can't be too negative, either. There were many times when I was hearing the same diatribe on straightening cords, drawing blood, or ventilator settings every day. The tendency is to roll your eyes and say "Can you teach me something I haven't learned yet?" But the worst thing in critical care (besides coming off as incompetent) is to come off as cocky. I'm glad I did ICU; it's the only place I feel challenged enough. And despite the hurdles, I would do it the same way....but a little more self-assured. Be kind, thorough, conscientious, and don't EVER let yourself gossip at work. Have a good attitude, ask questions, and you'll be fine. Good luck!

Hi everyone, I'm new here, but I'm wondering if anyone else's unit has this problem. I work in a small hospital. Our ICU census is usually 8-11 patients. However, we take EVERY kind of patient short of a transplant. A recent census of ours: fresh CABG, a patient in 4-points, a vascular surgery, a sepsis patient, a craniotomy, a crashing surgical, a cath needing sheath removal, a chemo patient, a GI bleed....I could go on. We also do CVVH, IABP, and all stat/first responder/code team calls in the house. While I like having variety, I am very leery about us getting complex surgical patients only sporadically. In my book, it's nearly impossible to be a perfect CV/neurosurg/MICU/SICU/CICU nurse all in the same week, when you only get to take care of a certain kind of patient once a month or so. Our hospital loves what the surgicals do for business, but it leaves the nurses and patients vulnerable. Not to mention about half of our staff have less than 2 years experience (i.e. new grads who went straight to ICU). Is this situation normal? Can anyone else feel my pain? HELP!

i would keep it in with wider parameters. we have VAMP attachments on our ART lines, so we draw hourly blood sugars from them, too. it saves a poke, and the "waste" is returned to the patient safely. so i guess i'm all about leaving them in....as long as you have SOME kind of a waveform/disconnect alarm!