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!