phoenixfire

I'm in a similar boat... been off of orientation in ICU for a couple of months now, looking at ACNP. I think it would be manageable, but my problem is that I have no desire to leave my hospital or the area that I live in, and there are no jobs here for ACNP's. My hospital won't hire them, and while the MD's are willing to let me do my clinical hours with them, none have jobs available. If this is what you really want, I think you should go for it, because education is never wasted. But consider how far you are willing to go, and whether or not you are willing to relocate if needed to get an ACNP job. Good luck

I know that the hospital I work at says NOT to bolus.. but here's the thing: not every patient will respond the same way to the same sedative. Propofol is what we usually use, but some people don't respond well to it. If your patient is requiring several boluses per shift, and pain control is not helping, maybe its time to switch to a different sedative. Look at your patient history: drug user, takes a lot of pain meds at home, has a chronic pain issue, etc. Same for pain control, some people need Demerol because Morphine doesn't work for them (had this fight recently with a surgeon!). Ultimately, it is YOUR patient, YOUR license... don't risk either on 'what if's', 'probably's', and 'that's the way we've always done it's.

I've made a notebook I labeled "ICU Pearls" full of the 'pearls of wisdom' i've collected from the seasoned nurses. Some of the best tips I've gotten are: 1- always make sure that your pump is programmed for the concentration of the drip you are running 2- chart the concentration of the drip bag on your initial assessment 3- always zero your invasive lines at the begining of the shift 4- dont ask for or use dopamine as a pressor if your pt is already tachycardic (you can ask for/use Levo instead) 5- ALWAYS ALWAYS ALWAYS make sure you have IV access, preferably large bore (a 20 is good, but 18 is better). I won't take report on a pt coming to ICU unless they have at LEAST 2 IVs 6- take the initiative, meaning don't wait until an hour before shift change to see what your coworkers need if they are busy and you aren't. 7- right after you take report, check your labs and orders to see if there is anything you need to call the MD about, especially if you are working nights. 8- talk to your patients and their families about what THEY want for end of life care. dont wait until your pt codes, and have the family screaming at you "This isn't what they wanted!". 9- trust YOUR gut... even if it seems silly, that instinct is there for a reason. thats all i can think of for now, but i'm sure i will think of more

I'm kind of on the fence with this one... on one hand I feel like its extremely difficult to care for a patient when I have to worry about their family member too. On the other hand, I wonder if allowing one family member (usually the spouse) to stay with the patient wouldn't be better for their peace of mind. I think the problem is that patients and their families are the ones pushing for more visitation... not the nurses. I have allowed family members to stay if they are polite and understanding of what my job is: to care for their loved one. I've also kicked family members out (especially when there are 30 of them that all want to pack in!).

Something I learned recently... be aware of what the costs are if you work with Medicaid pts. I had a pt that needed a Flexi-Seal, and two things happened. One, my coworkers said I could call the MD in the am to get an order to cover the tube, and the Cdiff culture I wanted. Two, they said the Flexi seal is too expensive, and urged me to use a regular rectal tube from xray instead. I DID call the MD, because its just not worth my license to place an invasive tube in a pt when he might not have wanted it, or ordered a lab he felt was unneccesary. Thankfully, the doc is a nice guy, and gave me the orders for both. But I did end up using the rectal tube from xray, one because it was easier to get ahold of then the high dollar one from the house supv, and two because it was cheaper for the pt. I don't like it as much, because I don't think it works as well (smaller opening in the top of the tube) but for pure watery stools, it worked great.

Being a new grad DOES NOT MEAN YOU TAKE ALL BLAME! I can't stress that enough! I recently got thrown under the bus by a seasoned nurse that I thought I could trust, and when the write up came, I refused to sign it because it was a complete lie! No one should ever ask you to assume all the blame because you are a new grad. We might be green in some areas, but that doesn't mean that we are stupid. Its high time some of these 'seasoned nurses' understand that. Not all experienced or seasoned nurses are hateful, but when you run into one that is, don't back down! Stand your ground firmly and with professionalism, but don't allow yourself to be their scapegoat.

I'm slightly less polite than this... if he continued to hang up on me after the first time, I would simply continue to call him back, and when he finally answers or stays on the phone long enough, I would say sweetly and kindly "Sir, I very much need your attention for (patient name)" and continue with what I needed. You can't change another person's behavior, only how you choose to react to it. Often, people assume that when we get angry, we are being defensive (a sure sign of guilt). So be persistant and professional, but don't allow this person or their high school habits to interfere with your ability to provide care. Good luck!

I keep a little list in my head of things to do before I call the doc: VS, I&O flowsheet (we use computer charting, so I can pull up a list of the last few days) for a positive or negative fluid balance, manipulate Foley tubing (move it around to see if it is kinked or clogged), irrigtate it if necessary, do a bladder scan if you think for some reason the Foley is out or moved, check the meds they are on and see if there is any reason they might not put out a lot of urine, but most important CHECK THE PATIENT. Especially on nights, where some people don't urinate as much or as often. But if you are not checking hourly urine outputs (like for a pt with an IABP, or a fresh CABG), you may not notice it as quickly. And I always dig through my charts to see if the pt has a history of CHF, lots of times that gets skipped.

I've been working as an RN for about 8 months now in ICU, and while I'm by no means an expert, in ICU I can tell you that you have to have a passion for it. We learned lots of things in nursing school, and most of it is relevant. One of my senior nurses told me that to be successful in ICU, you have to have really good BASIC nursing skills. If you aren't feeling confident about it, you could probably ask to work on a lower acuity unit for a while until you are really ready for ICU. But don't agree to take intensively sick patients if you don't feel you are ready, you won't do yourself or those patients any good. We may be nurslings, but no one knows us better than we know ourselves. Take the time you need to get the skills you need, you owe it to yourself and your patients.

Hi all... I've been hooked on this site since nursing school, but now I have a different dillema... I'm learning to be a critical care nurse, with an eye towards CCRN sometime in the next few years, but a few days ago, I happened to be the first person on site after a really bad car wreck. I rendered what aid I could, helped the EMT's as much as I was able, but I was fascinated with the experience. I love my job in the ICU, but I am considering cross training to trauma. For those trauma nurses out there, what advice would you give me? The crew chief at the wreck asked me after the Care Lifted the pt to a hospital asked "Wanna go to another wreck?" and he was serious! I'm intrigued with the idea, but haven't been able to find any information on RN's who also can do Paramedic stuff. Any advice is greatly appreciated!

One thing I have noticed on my unit is that the seasoned critical care nurses are more helpful when I ask for their opinion if I tell them a) what the problem is and b) how I plan to fix it. The more experienced nurses know that we don't know everything, and they expect us to ask questions, but they also expect us to at least have a battle plan ready for them to review. Don't just go ask them "What would you do?", ask instead "This is my problem, this is what I'm thinking will work, what do you think?". You'll get a better answer, and if your solution is the correct one, not only have you gained confidence in yourself, but you gain the confidence of the people you work with as well. Mucho important! Also, if your patient has recently had IV dye (like for a PCTA, etc) do NOT give Metformin for at least 48 hours, or you will send your patient into renal failure! (recent experience, didn't give it, but came close)

I think we are wearing the same shoes! All I can tell you is focus on those around you... look for people you respect, and ask them questions. I'm lucky enough to work in a place where even if my preceptor is not around, the other nurses will answer questions, or help me out. The only thing I would say absolutely do NOT do is pretend like you know what you are doing when you don't, or take on a procedure that you are not comfortable with! Either of those things will kill whatever motivation your teachers might have to show you things! One other thing I have learned: even if I THINK I know what they are going to say, I wait until they are done and then ask questions. Even if I'm fairly comfortable with something, the person teaching me may have something to offer that I wasn't aware of. Keep your head up, it will get better!

Amen!! The money we could save in preventatives alone with socialized medicine would be sufficient to pay for it, and then some. I know too many people who waited until they couldn't wait anymore to see a doctor, and what happens is instead of spending $100 on a doctor's visit, they end up owing thousands to a hospital for an ER visit, heart cath, and ICU stay. Just one example. There will always be people who do things like that, but the majority of those that I see every day do it because they don't have the cash to see a doctor the way things are now. I've read a lot of complaints about this bill, but honestly, don't we have to do something? The definition of insanity is doing things over and over the same way and expecting a different result. What we are doing is obviously not working, so its time to change something. Change is uncomfortable for a lot of people, but as we all know, just because something has been done a certain way for a long time does not mean its the right way to do things. If it were, there are a whole bunch of us that would not be nurses right now!

One thing that has to be addressed in this discussion is how much education the family members get when they are approached about this particular topic. Most of the families I have run into are concerned that their loved one will be in pain, or will be let die without treatment if they are an organ donor. I have successfully been able to educate two families who beforehand refused organ donation because they did not understand what was going on, or what was going to happen. People have the right to take their organs with them to their coffin, but at the same time, I have to mention that the law needs to reflect the PATIENT'S wishes, not the families. The way the law reads right now, I can be an organ donor all day long, and my driver's license reflects that, but if I am unable to communicate and my husband says no, there is nothing that anyone can do about it. He has the right to override my wishes regardless of what is on my license.

With ulcerative colitis, think of things that are non-irritating to the GI tract (ex. stay away from caffiene, spicy foods, etc). Stick with a bland diet that is higher in the elements your patient specifically needs (check your nutrition book). Also, you need to think about electrolyte imbalances past just sodium.. what else can a person with ulcerative colitis NOT absorb? B12. You can give it IM, but you need an order for it. You also need to monitor the condition of the perianal skin because of the diarrhea, that area can get very sore very quick, making your patient extremely uncomfortable and opening the door for skin breakdown. Grab your path book, and look at your medical diagnosis. If you understand the patho behind the diagnosis, you can figure out what to do/not do. This patient probably needs anti-inflammatories, and at worst case, may need TPN until the GI tract has had time to rest. Check with your hospital/clinical area's protocols to see what the requirements are. TPN has a high infection risk, and has to be put through a central line. It is best if you can avoid it, but if the GI tract can not heal, it may be the only option left. Good luck with your careplan!

Just to give a little backgroud, before I switched to nursing, I was in the military for several years, and I almost always got put on an all male crew. It always started out the same...I had to work twice as hard, and be twice as good as they were for them to respect me. But at the same time, I didn't take any crap from them. It takes time to build a working relationship with anyone, male or female, and you have to be the endurance runner and not the sprinter when it comes to building that relationship. With some men, all you have to do is ask, and with others, you have to bolster their ego. Its almost like dating without dinner and a movie sometimes. For me, the key to working well with men was to be one of them. Some women tend to want to be friendly with a man the same way they would with a woman, which is not likely to work well. Men are (often) straightforward, problem solvers, anlalytical thinkers. They want to be presented with a problem that they can fix. Mind you, this is just my experience, and does not apply to all men, so please don't flame me. In your situation, I think that maybe they are looking at you as an outsider, and until you build that working relationship with them, it will continue. For me what worked was offering to help them, "Hey if you can start this IV for me, I can take care of that blood over there..." etc. It sounds like you are willing to roll up your sleeves, so it shouldn't be a problem. The other poster mentioned taking them aside and having that little converstation will work well to. Good luck.

To stay on topic, I can tell you that I recieved my first two degrees from UOP, and it was harder than the prerequisite classes I took at a brick and mortar college for nursing! Part of what makes it so difficult is that to be successful in an online class format, you have to be a self starter. There is no teacher there reminding you every step of the way, you won't bump into a classmate to share a book with on your way to the lecture hall, and you have to be able to critically think. If you fail to plan, than you plan to fail. It takes dedication and excellent planning to attend an online class and be successful. With that said, it was financially more attractive for me to attend a local ADN program first. I will be pursuing a BSN online, because I work nights, and that works better for me with my schedule. Who wants a nurse that has been up all day in classes taking care of them all night simply because 'a brick and mortar school is better'? I can tell you that I would not... I think it has been mentioned here before, but I will say it again because repetition is the mother of retention: do your homework. If the employers in your area are not particular, than go to the school that best meets your needs. Also, if the employer has an issue with one college or another, it might be prudent to find out the reasons why. Accredidation is not arbitrarily handed out to any school that hangs a sign up... there are criteria that have to be met. Check out the federal board of education website if you need to know what the criteria are. It has been my experience (not a generalization, just my experience) that people who are bitter towards UOP are that way because they were not successful in the program. For whatever reason, they took their own ineptitude and turned it towards the school. Any college is a business, regardless of whether it is a profit, or not for profit, and will be run as such. In addition, one of my nursing instructors got her Master's in Nursing from UOP....two of my co-workers have a degree from UOP, and I hold two myself. Find what works for you, and go with it.

Ok, maybe I am looking at this with inexperienced eyes, but having worked in both places (as a tech), I have heard from both sides. I know that when I am in ICU, and we recieve a trauma patient, the nurses tend to be ***** because the patient is a mess... I mean blood and dirt still on them, etc. In my mind, this gives me (the new grad) an opportunity to do a really awesome assessment. I bathe them, note any wounds, scratchs, scrapes, etc that were not in report, assess pulses, look for bruising, broken bones... etc. In the ER, I know that the primary goal is to stabilize the patient... not necessarily make them pretty. I'm just about to start in the ICU, but having done several rotations in the ER, and been floated there plenty, I know that I will not be one of those catty nurses that complains about the patient they just got... blah blah blah... Perhaps you could arrange a meeting of some sort between the departments. What you need, what they need, etc. It would probably help if you also told the other side what they do well.

wow, some of these are pretty awesome, I'm laughing myself silly! Ok, one on me: begining of 4th semester, so hanging a new bag of NS should be a piece of cake, right? Nope. My instructor (a fearsomely smart woman who is not my biggest fan!) is standing there watching, and I manage to misprime the tubing! I wasn't holding the bag high enough, and so there were a boat load of bubbles all through the tubing. Took almost 100mLs to clear it.... thankfully, we were not in view of the patient, so he didn't hear my intructor tell me that it was gonna be okay. I mean, by this point, I should have been able to do it with my eyes shut, but having her standing right there, I just freaked... started crying and everything... ugh... and I'm SOOO not a crier by nature. Rest of that day went okay, but it seems like I only screwed up when she was watching me! Go figure... One on a friend of mine: first semester, in the nursing home, she was assigned to help this thin elderly man get his morning shower... and she is super grossed out by poop.. (can you see where this is going?). We get him stripped in the shower chair, wheel him down to the showers, and all the way into the bathroom. Shower goes okay, but on the way back to his room, we realized that he had been eating Red Hots... and there was a traily of poopy Red Hots all the way down the hallway!! We had to take him back to the shower and do it all over again, as well as help clean up the trail! To this day, she can't eat Red Hots, or even look at them again...lol

You can look at it a few different ways...why is this patient needing information? He had a procedure, right? So your NANDA would be something along the lines of "Knowledge deficit r/t surgical wound care secondary to mechanical interuption of skin barrier" etc. Sometimes I have to look at these things backwards and work my way forward. You just have to think about the WHY part... good luck!

I love critical care... because there is so much to learn, so much to do, and so many opportunities to teach and make a difference. I love to explain things via patho, and when your loved one is attached to dozens of tubes and recieving meds you've never heard of, I think that people appreciate knowing those types of details. Personally, critical care is a challenge for me (not that any part of nursing is easy) and that makes it more intriguing. I like being able to focus all of my attention on one or two patients, and really being able to think about everything that is going on with them. There is so much detail, and so many pieces of a puzzle that have to be put together to see the big picture. :redpinkhe

it depends on the wound type. For example, a surgical wound is changed for the first time usually by the surgeon, then he/she will order how often they want it changed, but usually prn. A decubitus may need to be changed only once daily, or once per shift. A few tidbits I've picked up about wound dressings: you should almost always premedicate the patient, especially if it is a large wound that requires manipulation of the surrounding tissues. Keep a sharpie handy (they have the little ones that attach to your badge at Wal-Mart), and put a date, time, and your initials on the dressing when you are done. If you just changed it a few hours ago, and you see drainage coming through, outline it with your sharpie so that you can best estimate how fast and how much it is draining. JP's are usually emptied at least once per shift, unless they need to be emptied more often, but keep track of how much and when you emptied it. You don't want to be the nurse (or tech) who cant tell the surgeon how much its drained during your shift! Hope this helps..

Ok, so I'm super excited... I just got my first job at an ICU, a place I LOVE TO BE. There is so much going on, so much to learn, and so many ways in which we can make a difference. I asked some of the seasoned nurses that I work with now (I'm a part time tech in an ICU unit) what I can do to be successfull in my new job. Some of the replies I got were a little.... disturbing. I was told not to voice my opinion (ever) because since I'm a new grad, I haven't earned the right to have one (apparently, you can only voice an opinion if you are an experienced nurse). I'm not supposed to ask certain questions because that is questioning the judgement of the nurse, and not the procedure (no matter how the question is phrased). I'm at a total loss. I've worked my tail off to get this far, and I found a place where I really want to be, but feel like I'm being chewed up and spit out by the same people that are supposed to teach me so that when they retire or leave the unit, that knowledge won't get lost. I've gotten to a point where I'm questioning myself as to whether or not I even want to be a nurse anymore. I know that I don't have the knowledge or expeirence to walk into an ICU and take care of a critical patient... but I'm willing to learn, and I don't know how I'm supposed to do that if I can't ask questions or have an opinion. I've been told that I'm not a team player, and that people in general do not like me because I'm aggressive and independant, too focused on the details, and have 'an authoratative tone' when discussing concepts. I know that I shouldn't let one instructor review, or even one or two other nurses opinions stop me, but if I'm getting this from multiple places it really makes me wonder if I'm cut out for this... I'm struggling to figure out how to fix this so that it doesn't become a problem in my new job.. I just don't understand. If I'm caught up with my patients, I ask the other nurses if there is anything I can do to help... If the doctor comes in for an update on a patient that I've been with all day, do I let my preceptor answer him, or do I speak up? If another student asks me a question, and I know the answer, I tell them (and if not, we look for it together). If I don't understand why we are doing something, do I question it, or do I accept the judgement of more experienced nurses? So I guess my question is: How can I be successful in my new job? What can I do to NOT be perceived as a...witch...? Any guidance would be great...

First, let me thank the two responders to my question. I'm not an A student, per se, I'm an A+ personality type. I often have to step back and try to bite my tongue, or sit on my hands when all I want to do is jump in and help. The hardest thing for me during clinicals is feeling so completely incompetent. The nurses that I work with in my tech job are AWESOME and are willing to teach and allow me to ask questions and help when it is feasible. They often discuss with me after an event what the play-by-play is/was, and how they know those things. I have done some serious thinking on why I failed the clinical portion, and in doing that, I can see that I do need to repeat the course, because I wasn't able to show my instructor what she needed to see. I know that working as a tech is a great experience, and that experience is valuable. What it is not is a pass through the critical care course. On one hand, I feel like I was expected to know more than the other students because of my job, and on the other hand, I feel like my job just illuminates for me how much I DONT know. The more I see and experience, the more I realize "Holy crap, I don't know jack!". And the more opinions I listen to, the more I can piece together the big picture, like pieces of a puzzle that show the whole scenario. While it is devastating to me personally to have failed, it also makes me want to double my efforts, because this is the first rotation during nursing school where I feel like "YES!! This is where I want to be!", and in order to be accepted in the world of critical care nursing, I have to make some changes. Thank you again, for your insights.