RNinICU

How was I supposed to know she didn't know what she was giving if she didn't ask? Had she asked, I would have explained the difference. And as far as the patient not being harmed, he had to undergo an extra dialysis treatment to remove the excess potassium. A mistake like this could have been fatal. I don't believe in being harsh with new nurses, but just like any other profession, there are some people who do not belong there. I have had my hair ruined by a bad stylist, and my meals ruined by a waitress who did not know what she was doing. A mistake made by a healthcare provider can have devastating effects. Part of my responsibility is to be a patient advocate. If anyone thinks that covering up a mistake like this is OK, then I am afraid for our profession, and our patients. By the way, I would write up a physician, a respiratory therapist, or a housekeeper if they did something to endanger a patient. I have written up a physician in fact. I don't write people up frequently. In twenty years, I have probably not written more than 5 or 6 people up. Each time there was a blatant error that jeopardized a patient.

There is a huge difference between covering for a co-worker, and covering up for a co-worker. Helping and supporting our fellow staff increases patient safety, IMO. I would never let another nurse flounder, but I would also never let another nurse compromise patient safety. I don't mind calling labs that the previous shift forgot to call, or changing a dressing that was missed. But if something critical is missed, or a serious error is made, I will document the error. For instance, a few months ago I floated to another unit. A patient with renal failure and a high potassium was ordered Kayexalate. A new nurse took KCl out of another patient's drawer, and gave that instead. Had she come to me, I would have happily explained the difference between the two meds. Instead she gave a med she was unsure of, and jeapordized a patient. This is the kind of thing that cannot be overlooked, and I did write it up.

Couldn't have put it any better than this.

I would actually like to see our hospital go back to team nursing. I think that patient satisfaction was higher, and staff was happier with this method of care delivery. LPNs at our facility are now basically med nurses, and aides do most of the direct care. I think the LPNs felt more valued when they had more patient contact. And I am not putting down CNAs, but I believe that LPNs are more likely to see a developing problem and either intervene, or bring it to the RN's attention than an aide is. There were disadvantages, too. Some times a 12-15 patient workload could be overwhelming, especially if acuity was high. You could also get tied up with a patient that was having problems, and your other patients would be slighted. All in all, I liked doing team nursing. Hope this helped a little more.

We did a form of team nursing at our hospital years ago. An RN was in charge of each team, about 12-18 patients. RNs were responsible for assessments, signing off orders, patient teaching, physician rounds, calling docs, giving IV meds and generally managing patient care. There would be two or three LPNs on the team, each assigned 5 or 6 patients. LPNs did all direct patint care, including giving meds, dressing changes, bathing, and most of the documentation. There would usually be one aide split between two teams to help with care. We have not done this kind of team nursing for years though. You may have a difficult time finding resources. Hope this helped.

I was raised in a small town, and went to an all white school. I had very little contact with other ethnic groups until I started working. We have a few Blacks working in every department of our hospital, from Nursing to Dietary, and a few Hispanics, but most of the employees are white. I have never had a problem working with any of them, and never felt uncomfortable delegating to anyone, or accepting delegation from anyone either. This thread has reminded me of several incidents where race was a factor. Please forgive me if this gets too long. I do a lot of teaching, and frequently speak on health care issues for community groups. One of my coworkers asked me to speak about breast cancer to her Church group. On the day I was speaking, I walked into the Church, and discovered that I was the only white person there. I was completely surprised, as it had never occurred to me that this was an all black Church. After the presentation, my friend asked me if I had been uncomfortable when I had first entered the Church. I had to tell her that I was a little, but more because of the size of the crowd than their color. By the way, this was one of the best audiences I ever had. They were attentive and involved in the speech, and asked a lot of questions after wards. I have gone back to this church to speak several times since, and I am always just as wel received. Another time, my husband and I were in New York City, and were a little lost. We stopped in a McDonalds to eat, and were the only white people in the restaurant. Everyone there kind of stared at us, but they did not seem hostile, just curious. For the first time I knew what it felt like to be part of a minority. Right after my daughter graduated from high school, she went to Philadelphia to work, and lived there with her brother for a while. She would frequently come home for the weekend, and often brought a friend with her. One weekend she brought home a black girl. The two of them went to a neighborhood store to pick up a few things, and my daughter came home livid. She told me that she was so humiliated for her freind because the entire time they were in the store the clerk watched them, as if he was afraid they would steal something. Keep in mind that my daughter had often visited this store and was well known there. She left the clerk know what she thought of him, and he told her she should know better than to bring that ------ into the store. My daughter was actually more upset about it than her friend was. I guess the point I am trying to make is that we have come a long way, but still have a lot farther to go. Maybe someday when we make contact with beings from another planet we can stop hating each other because than we will have someone new to hate.

I think this bears repeating.

Thanks for the suggestions. Our docs seldom use Angioseal. When they do, we have had very few problems with it. Almost all of our caths are on Integrilin or Reopro post procedure, and most of them get Plavix, too. Until now none of these meds has created a problem. One of our cardiologists always uses a Fem Stop, and he seldom has problems with bleeding, but the patients hate it. We always hold Lovenox twelve hours before caths too. ASA is a different story, it is usually only held 24 hours pre-cath. Our patients don't leave the cath lab till their ACT is 180 or less, and the cath is not pulled until it is less than 150. We have looked in to all of these things, and still found no connection. I don't think anyone thought to investigate the use of herbals or other homeopathic meds the patient might be using, but it's certianly something worth finding out about. We ask people about herbals when they are admitted, but in my experience, some people are embarrassed to admit they use them. I certianly don't mind if they start pulling sheaths in the cath lab. I hate being tied up for 20 minutes or more with my hand in someone's groin.

In our ICU, the patients usually come down from the cath lab with the sheath still in the groin, and the RNs pull them after a few hours. Until recently, we have not had too many problems with pulling them, a small hematoma on occasion, and a couple of pseudo aneurysms, but for the last two weeks, we have had some major complications. We have had five pseudos, two that required surgical intervention. We have also had two retroperitoneal bleeds, and one woman who bled so much she went into hypovolemic shock, arrested, and had to be intubated for two days. Thankfully, she survived. There have been no apparent commonalities between these cases. The caths were done by different cardiologists, and the sheaths pulled by different nurses. The cardiac docs are kind of blowing it off, saying it's just a cluster of complications, and that it's not significant that so many happened in a short time. Our Intensivist, who is also our medical director, wants all sheaths pulled in the cath lab with the doctor present. The cardiologists of course are against this. How do you handle arterial sheaths in your unit? Who pulls them, and has anyone else had these kinds of problems?

Use the quote button at the botom right corner of your screen.

You mean this isn't the most important thing?:roll

I will not post my location or the name of my facility on a public forum for obvious reasons. If you want to talk to me about anything that specific, you can PM me. I do work with several people who visit this board.

Most probably, this was a PEG feeding tube that was inserted through the abdominal wall for long term feedings. If it is accidentally pulled out, it can be reinserted through the opening left in the stomach wall. This is a common practice in nursing homes, but it must be reinserted carefully. Placement must be checked by aspirating stomach contents to make sure the tube is in the stomach. On occassion, the tube can pass between the abdominal wall and stomach, and instead be placed in the peritoneum. If tube feedings are given without checking for proper placement, they can be instilled into the peritoneum, causing peritonitis. In this case, it sounds as if the feedings were being instilled into the peritoneum for quite some time. I have seen this happen once before, and this lady also died. In a hospital setting, reinsertion of a PEG is usually done by EGD to prevent this kind of thing.

Last night I was scheduled to work 11-7, and was afraid I was going to end up with overwhelming responsibilities again. I called my unit to ask about acuity and staffing and was told I would be there with an LPN, two newer staff, and my orientee. Two other more experienced nurse had been called off for low census. Acuity was still high. I called the supervisor, and told her if she did not call in one of the experienced staff, I would be calling off sick. Amazingly, one of the older RNs was called in, and one of the newer people was given the night off instead. Last night went much better, and I actually got to do some teaching with my orientee. We all must start making patient safety a priority, and refuse to work with unsafe staffing levels.

Yes, we do put someone on call when they are called off for low census, but in this situation, the patient load did not increase, and we are staffed by "numbers." If we received an admission through the night, I would have been allowed to call another person in. At the beginning of the shift, I had expressed concern about the staffing, and was told by the supervisor that there was no way I was calling another person in. Our unit manager has been trying to get the staffing by numbers changed, but so far has had no success. She is frustrated herself, and is thinking of leaving her position, in part because of our staffing problems.

JeannieM, What does this RN do? We have a staff member like this too. She ends up taking care of the vascular surgeries and other less complicated cases. But the RN who was given off that night was a competent, experienced RN who would have made my night much easier. This is another thing that needs to be looked at in the staffing mix. I am not putting down newbies or LPNs when I say that there are times when you need another experienced RN to help with the patient load. Unfortunately, this kind of situation is happening more frequently in our unit. Or if the census is high, we often need to pick up a third patient instead of calling another staff member in. We hear about budgets and money all the time, but little about patient safety.

I had another bad night at work last night, and the worst thing about it is that nights like this are beginning to be the norm. Our community hospital became part of a major health system about two years ago, and things have been getting worse ever since. Seems the bottom line is the major motivator for these people. Last night we had seven patients in our ICU, staffed with two RNs with less than six months critical care experience, an LPN, and myself, along with a new orientee who has been with me for only a week. There was another seasoned RN scheduled, but she was given the day off for "low census." My patient was a septic shock with renal failure, CVVH, hourly accuchecks with an insulin drip, PA line, ordered q4h hemodynamics, and multiple other drips. His MAP was never above 55 all night. All of the other patients were high acuity also. There was a cardiogenic shock on an IABP, an active GI bleed, a post arrest and a massive CVA who was seizing. My patient was 1:1 so I was expected to cover the LPN, giving her IV ativan and dilantin for her CVA, calling her docs, and signing off her orders. The other two RNs were so overwhelmed with their own assignments, that they were little help. As a matter of fact, they both came to me several times through the night for help and advise. When I protested about the RN being given off, I was told "Your numbers only call for four people, and you have an orientee who can be an extra pair of hands." So I asked why one of the newer people or the LPN had not been given off instead, I was told that it was Nurse A's turn to be given off. Now the new girls and the LPN think I was complaining about them, and I wasn't. I just thought someone should have used a little common sense and looked at the staffing mix and acuity. I documented my objection to the staffing and assignments and gave a copy to my unit manager and our DON, but I don't think it will do any good. When I talked to my unit manager about the situation, she confided that she was thinking of resigning her position because of problems like these. I have always loved my work, and this hospital, but with the big corporation mentality that has taken over, I don't know how much longer I can continue to work here. The only problem is that the other hospital in our area is part of another corporation, and has similar problems. All I want is to give safe and competent care to my patients, but I feel that I can no longer do this. There are safe staffing laws before the legislature in my state. They can't be passed soon enough, IMO.

We have a closed unit and do not have to float out of ICU if we don't want to. We have the option of taking a day off if we have a low census, or of working on another unit. None of our specialty units have to float, but we also do not get help from the other units when our census is high or staffing is short. We cover our own. On occassion, someone from the telemetry unit or stepdownunit has come in to ICU to help out, but they never have an assignment. Instead they do tasks like IVs and signing off orders. Some of the med surg units are very resentful of the fact that we do not have to go work on their floors when they are busy and we are not. Of course, these are the same people who think ICU is eay because we only have two patients. I usually will go out to the floors. Most of our staff simply refuses to float. I don't mind floating, and I have never been asked to do anything that I am not comfortable with. I will sometimes work on the floors even if it is not my turn to go if I know the floor is really short staffed. We also have a system for keeping track of who's turn it is to either take a day off of float. It seems to be getting more complicated though. We actually have a twelve page policy that outlines every detail of our self containment policy.

Dialysis is considered a critical care specialty in my area too. Many of our ICU nurses have cross-trained for dialysis, and we do our own inpatient treatment on patients in ICU. The dialysis team handles all other inpatient treatments throughout the hospital. As far as ICU nurses not being able to hack dialysis, that is simply not true. I find doing the same thing every day boring, and would not want to do it every day. After the intensity of critical care, dialysis is just too tame.

In your hospital, who approaches patients and/or families about the patient's code status? If a patient takes a turn for the worse, and some one needs to find out how aggressive the treatment should be, do nurses or doctors talk to the families? Or if a patient has been on support for a long time and is only being kept going by the machines, who talks to the family about discontinuing treatment? As an ICU nurse, I have often updated families about a patient's status, and discussed the option of making a patient a DNR or discontinuing an ineffective treatment. Only one of our docs has a problem with the nurses talking to families about code status. He is an older doc who seems to think that the nursing staff is usurping his authority. My SIL works in another state, and she tells me that nurses at her hospital never discuss code status, only the docs do this. I am not talking about giving complicated details of treatments and procedures, I am just talking about finding out from families what their wishes are regarding code status.

There is one girl in our unit who doesn't mind if the this intrusive staff member does her care, because then she doesn't have to do it. That one is just plain lazy, but she always tells Nurse A how wonderful she is and how much she depends on her. This just feeds into Nurse A's ego. I think that is a big part of her problem. I think she needs to prove to herself and everyone else that she is the best nurse in the unit. I have tried giving her some positive reinforcement when she stays away from my patients and does something good for her own. This has helped a little, but I don't always have the time (or inclination) to stroke her ego.

Quite a few of the nurses I work with are very territorial about their patient care. I have to admit that I don't like other nurses messing with my patients either. I don't mind if someone answers a bell or hangs an IV for me when I am busy, but there is one nurse in particular who just cannot keep her nose out of other people's patients. She will suction vent patients even if their assigned nurse has just suctioned them, she turns them and rubs their backs, and even updates their families and calls doctors about patients other than her own. She has been heard telling patients that she is a much better nurse than the one who is assigned to them. I don't know how she finds time to become involved in other patients and still have time for her own. She has been "talked to" about this behavior, but always has some excuse for what she did. "The patient asked me to turn her," or "The family had questions, and I didn't know where her nurse was." These are not situations where the patient is not receiving care from his own nurse, they are episodes where the assigned nurse is busy for a minute or two, and will get to the patient shortly. Some of us have told her very bluntly to stay away from our patients. She has learned to keep away from my patients, and a few others, but continues this behavior with others. She is especially intrusive with one of our newer nurses who is a little timid yet. I have on occasion stepped in when "Super Nurse" was giving her a hard time, but can't always run interference for her. We have also tried pulling the same stunts on her, but that hasn't helped either.

I've been offered the position of house supervisor. I love bedside nursing, and never thought about moving into management before. Now that the job has been offered, though, I have been thinking about accepting. What do you like, and what do you dislike about being in management? Can you give me any advice about what to expect. One of the things that bothers me most is that I will be expected to support policies that I do not agree with. Any advise will be greatly appreciated.

The verbally abusive nurse was not an isolated incident either. This has been an ongoing problem with this particular staff member, and we had a lot of documentation. I had confronted him in the past, as had several others. He had been suspended for this behavior a few months ago. The full details are in the thread "When nurses are mean to patients." Sorry, I don't know how to put the link in.

RNPD, I usually use the same criteria for writing people up. I don't like to do it, and don't do it for minor things, but I WILL NOT compromise patient care in any way. There are others in my unit who write people up more frequently than I do, it just happened that these two cases occurred within a very short time frame, and had more serious consequences. I'm sure it will blow over eventually, but in the meantime, my manager knows the situation. I am not worried about a few others writing me up for minor things, I was just surprised, and maybe a little hurt that people I consider my friends would react the way they did. This too shall pass.