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Sugarcoma RN

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Sugarcoma has 2 years experience as a RN and specializes in Trauma/Tele/Surgery/SICU.

Wife, Mother, collector of discarded animals, student...once again!

Sugarcoma's Latest Activity

  1. Sugarcoma

    Rapid Response VS Code Blue?

    I agree with Esme, don't get hung up on the words, just get help when you need it. I respond to Rapids and codes and for each you will get an ICU rn, a doc, and an Rt. The only difference is a Crna will come to codes without being called. One of the Swat rns at my first nursing job made it very simple for us to decide between the two. He said "I have ten minutes to respond to a rapid and three to a code, if you don't think your patient will last ten minutes, call a code."
  2. Sugarcoma

    CSICU nurse to pt ratio??

    Hi only him. I am sorry I did not see this sooner and I hope you did not already have your interview. The last 2 interviews I have been on they have been really big on questions about conflict. Conflict with patients, coworkers, etc. For example on both I was given a scenario about a coworker using hospital computer to post on facebook while their patient needed something and asked how I would handle that. On both I was asked about how I would deal with a scenario where a coworker and I had a disagreement about something. And on both I was asked what I would do if I saw a coworker doing something unethical or even harmful to a patient. For what it is worth in each instance I responded that I would address my concerns directly with the offending coworker in a professional way. In the facebook example: nurse Mary I see you are busy on the computer but I noticed your patient's BP has been dropping were you aware of that? Can I call a doc for you? grab a bag of 0.9 etc? Also for what it is worth I did not get either job.
  3. Sugarcoma

    New to the SICU...

    Correct me if I am wrong but what I took from your post is that maybe you are a little concerned that your new manager doesn't realize exactly how new you are? You were honest about your experience. Your manager knows your experience. If she expects a fully functioning ICU RN who just maybe needs to learn the charting and where everything is then shame on her for hiring you. Please know that sometimes when a manager says they do not want to hire new grads that does not necessarily mean they are looking for an experienced ICU RN so much as they are looking for someone who knows the very basics of nursing such as how to talk to a doctor, how to hang a tube feed, how to start an IV or draw blood etc. And they are looking for someone who knows they will be comfortable in an ICU, someone who is not freaked out by vents and realizes the ICU is a serious place. In the case of my manager this is what she means. She hired two relatively new nurses, one with only 6 mos experience as a nurse and she always says she will not hire new grads. She was aware of what these really new nurses would need to succeed. I hope this is what you find with your new manager as well. My recommendation would be to be brutally honest about your abilities and experience with your preceptor/s and educators. If you have to, remind them that even though you come from an ICU it had much lower acuity. Tell them that is why you changed jobs because you felt you were taking care of glorified floor patients. Make sure your preceptor/s know that you are up for the sickest of the sick while on orientation. Use the next 6-8 weeks while you have a preceptor to soak up as much as you can. Honestly I think that showing up with a good attitude, showing a willingness to take hard assignments and showing enthusiasm to learn new things is most of the battle. Hopefully they will give you a little more time. 6 weeks orientation in an ICU seems short to me even for an experienced ICU RN.
  4. Sugarcoma

    My DON came to my house today

    This is great advice from icuRNmaggie!
  5. Sugarcoma

    My DON came to my house today

    This! Great advice from icuRNmaggie!!!!
  6. Sugarcoma

    Question from a clinical instructor

    You could give each student or couple of students mini case studies for different types of wounds. For instance: A pressure ulcer, an infected surgical site, an MVA with multiple skin abrasions, a vascular ulcer, an arterial ulcer, etc. You could ask them to identify what type or types of dressings would be suitable for each wound and ask them to identify what else would be important for proper wound healing such as nutrition/pain control/positioning etc. My mind is running away with this. Mr. smith is 89 years old and has been admitted to the hospital for pneumonia. He has a history of DM, CAD, and COPD. He is confused, has a foley, and is unable to ambulate or turn himself. Mr. smith has an area on his coccyx measuring 3x2 cm with a small area of dermis that is open (Picture of wound) Braden score for Mr. Smith? Identify the type of wound? What type of dressing would be appropriate for this wound. Is there anything in Mr. Smith's history that would cause him to be at increased risk of developing this type of wound? Aside from dressings what other aspects of Mr. Smith's care are important to facilitate wound healing? What action can the nursing staff take to decrease the likelihood of Mr. smith developing a wound like this in the future? I guess that would be a lot of work for you to come up with little scenarios for each type of patient. Pressure ulcers lend themselves to this type of assignment much easier than other types of wounds. This is more difficult than it seems because they are newer students without much exposure. Even a teaching plan or having them learn the types of products to present a mini inservice to their classmates would be limited by what they saw on their observation day. Maybe you could simply have them write up their experience with the wound nurse. What types of wounds they saw, what types of products used, what they thought of the job of wound care RN, why they think the job is important, what type of education is necessary to become one and if it is something that they think interests them?
  7. Sugarcoma

    My DON came to my house today

    I did not read every comment, just the first few from OP. Yes I would have held lasix for a patient with a K+ of 2.9 when it was not addressed. Lasix will cause an even further drop in K+ and at 2.9 that patient really couldn't afford too much more of a loss. The lasix was ordered for increased edema. I am assuming the patient did not have trouble breathing as they are not in a hospital. Where is the harm in holding one dose until the critically low K+ is addressed? I too would have sent out a patient with no bowel sounds, ab pain, and a firm distended stomach. I work with docs like this. They only want to be docs from 9-5 and they get all out of joint when we do things without consulting them, yet they are unavailable to us. The thing with these types of docs is that you are da$n#! if you do and da&ne* if you don't. Could you imagine how fast they would throw you under the bus if you did not call a bus for a patient who ended up perfing? Or if you had sent the lasix patient into a lethal arrhythmia due to hypokalemia. You can't have it both ways. I would call with everything, which is what I do at work. They don't like it, they yell and gripe and groan, but my patient's get what they need or at least I know I did what I could to make sure my concerns were addressed. Your don sounds like an idiot and I would never tolerate my employer coming to my home unless it involved a serious emergency. Is there anyone higher up you can complain too? That type of behavior is way out of line. Seriously she sounds a little unhinged. I would let this DON know that I am governed by the nurse practice act of my state, not her opinion, and that I will act in accordance with that act and not her opinion. I do not know where you live but I do know that my act includes the prudent use of nursing judgement. Firm distended abdomen with no bowel sounds = further assessment needed period. Could you imagine sitting in a court of law and trying to defend not sending this patient out for further assessment if this patient ended up with a perfed belly? Umm sorry but our docs don't like to be called at night and the DON comes to my home and rants like a crazy person if she doesn't agree with my actions? She is nuts if she doesn't understand why you did what you did in both instances. You need to find a new job ASAP. At the very least I would go above this DON just to make sure your concerns are documented. It may not change anything and probably won't but at least you will have tried and then can go about seeking new employment knowing you did all you could.
  8. Sugarcoma

    CSICU nurse to pt ratio??

    I work in a combined trauma/neuro/cardiothoracic/surgical unit. Our hearts are 1:1 for the first 12 hours post op or until extubated. I think that is pretty standard for all open heart patients, although I have never worked in a strictly CTICU. Windows and other thoracic surgery patients are standard 1 nurse for 2 patients unless step down status then they can be 1:4. There seems to be this huge misconception that I encounter frequently that ICU RN's workload is easier than say a Med Surg RN with 6 or more patients, having worked both I can tell you that is simply not true. Sometimes just one patient can feel like you are caring for 4 or more. A sick heart can keep you running like crazy all shift long.
  9. Sugarcoma

    Why do nurses delegate with a power trip?

    What you have chronicled has more to do with the work environment than anything else. You will find these on floors in hospitals, as well as LTC. When you have a chronically stressful environment where all employees are expected to do more than is humanly possible those employees will turn against one another. LTC in my opinion is set up for failure. The ratios are ridiculous. People become hardened working in these environments because they simply cannot do all that needs to be done. When aide A is written up by nurse B for failing to complete a task, what nurse B may not understand is that they were spending a couple extra minutes with a resident who needed a little TLC. Aide A will almost certainly become frustrated and feel devalued, like nothing they ever do will be good enough. Nurse B will also feel frustrated because she/he cannot do their job the way they want to. This will most certainly lead to conflict between the two and if this is repeated often enough will lead to possibly one or both becoming hardened and adopting a "who cares" attitude. In LTC there are fewer opportunities for aides to do tasks outside of cleaning, wiping, showering, walking, turning, etc. But we as nurses know that these are some of the MOST IMPORTANT procedures to our patient's well being both mentally and physically. We should never think of an aide as just a butt wiper. I wipe butts myself so who am I to make that type of judgement? Having an environment where the nurses can write up aides is ridiculous. The only person who should be able to write up an employee is the manager. The nurses should be able to bring their concerns to management but that is it. Working in this type of punitive environment is poison and you will end up with nurses and aides who work against one another and the loser in this is the patient. I am glad that your new job has shown you that not all nurses treat assistants like trash. This is the way it should be. We are all on the same team. As far as the name goes I personally like techs. Aide to me denotes someone with no training who assists. Tech is exactly what they are specially trained professionals who perform a vital role in healthcare delivery. The techs I have worked with have broadened my education when it comes to things like ambulating, moving, cleansing, skin care. etc. Believe me I still whisper thanks to some of them when I have a code brown and because of my expertly placed chux pads only have to change that instead of the entire bed! Or when I am the only one on my unit who knows how to turn an intubated patient completely off their backside so their pressure ulcer can actually heal. (this just happened recently! Thank you Yvonne!!)
  10. Sugarcoma

    Why don't you just read the chart?

    One of the facilities I work contingent at just recently addressed this via a committee of med-surg, ED, and ICU RNs. Per that facilities new protocol the ER nurse is only responsible for transmitting patient's age, name, chief complaint, allergies, last vital signs, what tests were performed via circling them on a sheet and what treatments they got in ed. They also list the results of any critically abnormal, though not necessarily abnormal tests. The ed RN may list abnormal labs that they did not treat such as low k etc. and whether or not a field start IV is present or not. This is it. There was quite a bit of grumbling from the ICU and med surg RNS to which the committee members sent us a letter that stated: "We expect that all nurses in all levels of care are performing critical assessments on each of their patients, including their response to any ordered interventions. You should be assessing your own body systems and if a change is noted from what was charted in the ED, alert the covering resident. The ED RN is not required to note the location or gauge of IV. Each nurse should be assessing the location, gauge, and functional status of IVs for themselves, every shift." When word got back via the ED RNs that it wasn't working out via phone they changed to a faxed report only and then the ED RN only calls the floor to alert that the patient is on their way up in 15 minutes. For ICU they still do a nurse to nurse hand off with that sheet and to verify what tests have been completed. They trace lines together and verify what meds are running and let the ICU know what still needs to be done. This facility also mandates that whoever admits the patient medicine, surgery, ICU, etc. have a complete H and P and completed med rec as well as an admission progress note in the computer prior to moving out of the ED. This facility also requires centrals and arts to be started in the ED by the admitting team if deemed necessary. The ED RNs do us a great service in that most of them always start a second PIV. So even if a patient arrives with a field start all we have to do is pull it within 24 hours. Most of them also include extra data in the notes section of the faxed sheet. Most of them will also alert the floor to problem family members etc. It has worked out surprisingly well and has resulted in an increased amount of communication between the admitting medical team and receiving floor taking the ED nurse out of the equation all together. I do both med surg and ICU at this facility and it works well in both areas. It puts the responsibility of communicating vital treatment information on the physicians via notes and orders which is where it belongs in my opinion. When I get a patient on med surg I can see via the doctors notes and the orders what their plan for my patient is. When I get a crashing patient in ICU I already know I have a verified usable central line and can hit the ground running.
  11. Sugarcoma

    Nurses Diverting Narcotics.

    These are excellent points! I did not realize dilaudid and others narcs were available in 1 mg vials. I also routinely pull out a full vial because no one is available to waste. 1mg vials would really be convenient.
  12. Sugarcoma

    Nurses Diverting Narcotics.

    Wow! icuRNmaggie my stomach fell to the floor when I read this. I do this all the time. I always figure since I am going to pharmacy I might as well get whatever they have waiting to save others the trip. This NEVER occurred to me! Thank you for posting this. I will be changing this practice immediately.
  13. Sugarcoma

    Do you titrate drips?

    I work in a combined ICU/SD unit. We take insulin,cardizem, nitro, cardene, and amio as stepdowns. Levophed buys you ICU status. Occasionally we will have that odd patient we just can't wean off levo who is on 2-4mcg as a stepdown. We do not use dopamine often at all but occasionally we will have a low dose dopa patient on stepdown as well. Cardizem has a limited range and is usually not titrated aggressively. I have only used it a couple of times for resolution of A-fib. I think a cardizem patient with a stable bp would be appropriate for SD. Same with Cardene as long as BP is not rising. Dopamine only depending on why. I have mostly seen dopa used for symptomatic bradycardia. As long as the range is small say 5-15 mcg and the HR and BP are remaining stable I would be ok with this as a SD patient. Levophed is an entirely different animal in my opinion. I really do not think levophed is appropriate for SD. We use levo for septic patients. As another poster pointed out a septic patient requiring levo for support can turn into a hot mess in no time flat. Do you have a central line and an art line? What is the range you can titrate to and what are the parameters? At what point does your SD on levo become an ICU? 10mcgs? 20? How do you do vitals in your unit? Do you have monitors that pull your data in or do you need to do manual vitals? Do you have docs readily available to you? I would encourage you to do two things. First, pull up your facilities policy and procedures related to levophed (and the rest of the drugs you mentioned). My hospitals policy requires anyone on levophed to have a central line once you go past 5mcg. Vitals are required Q 15 minutes and they require an art line and a foley catheter for critical I's and O's. The policy also states we can titrate Q5 minutes. In my opinion anyone requiring Q5 minute assessments belongs in the unit. The second thing I would do is find your hospitals unit admission guides. This should give you a rough idea of what is considered ICU versus Step-down. I would want to double check for myself that hospital policy states someone on levophed is appropriate for step down and see exactly what it says about at which point that patient should go to ICU.
  14. I have worked with a few and personally precepted two of these know it all types. I enthusiastically agree with the poster/s who suggested you distance yourself from this person ASAP. I would most definitely speak with your manager about your concerns ASAP. Any candid conversations or come to Jesus talks should really come from management. Know that they will most likely receive a new preceptor, not because your manager really thinks it will make a difference but so they can defend that every possible avenue to facilitate development was taken. In my experience these types of nurses take any type of intervention as further proof of their superiority (everyone else is clearly threatened by their greatness and out to get them). They glob on to protocols with all their might and are quick to throw anyone who deviates under the bus. They lack the ability to ascertain when deviations may be in order. They are unwavering in their beliefs. And make no mistake these types of nurses are absolutely unsafe because they lack the ability to see when they are in too deep and need help. I think it is very commendable and speaks well of your character that you would like to attempt to foster a sense of humility and humbleness in this person. Personally I don't think humility or humbleness can be taught. You either have it or you don't. Unfortunately for these types of people they are so insecure that looking good themselves trumps relationships with their coworkers and even their patient's well being. You really do not want this type of person as a coworker. Because they seem so sure of themselves patient families and even other coworkers, docs, etc. will often believe that they really are great nurses. They are fabulous staff splitters and can really bring down the morale of a unit. Often times these people will be transferred out to other units ASAP. If not new to nursing they will often have a history of multiple jobs or transfers. We had one who had been written up 3 times and the rule was in order to transfer to another unit you had to have one year write up free. The minute this nurse expressed interest in another unit to my manager she was on the phone and by the end of the day had somehow managed to arrange a transfer. I truly feel for you and I hope that you can find a resolution that leaves your sanity intact and this persons future patients safe.
  15. Sugarcoma

    So disappointed in hospital RNs and MDs

    Charting a physical assessment means physical assessment, not reviewed patient's chart. I work in ICU so I am familiar with how much time a doc may spend on an ICU patient. I fully understand that docs have huge demands on their time. I also understand that they have access to xrays/lab/vitals/fluid status etc prior to ever showing up. I understand they may have spent more time than I personally have seen with my own eyes and do quite a bit of work behind the scenes. We have some great docs on my unit and it is obvious they are paying attention. We also have some crappy ones who do not pay attention, rely on the nurses and residents to point things out to them, and this is also obvious. It is obvious when their charting does not match (could not) match the patient's /condition/test results/etc. It is obvious when they are entering d/c orders on patients who are either stopped from transferring by an attentive RN/resident or turned right back around and re-admitted by the receiving floor because they are clearly in trouble. Literally the assessments, notes, and plans they are charting totally contradicts the patient's test results, physical condition, ER presentation and computer captured vitals. If they would have at least laid eyes on the patient they would have noticed something wrong. Like the patient is breathing 40 bpm's, is on a NRB, is gray, and is absolutely not WNL respitorially and ready to be transferred out. Doctors are not the only ones guilty of this, RN's, resident's, RT's, etc are as well. When you have a group of them all working on the same patient for multiple shifts patients can and do get in trouble. When you can literally go through the chart and track an expanding bleed via CT for days on the patient who crumped "suddenly" despite being A&Ox4, GCS 15, PERRLA bilaterally, MAE for those same amount of days? When these incidents happen repeatedly, to the same people, over and over again? And it may not even be an issue of malicious intent. In some cases it may be inexperience/not realizing what they are seeing, difficult dx's etc. Like the tricky foot fx that isn't totally visible on xray. If you never go in and look at the foot, see the swelling, bruising, etc. for yourself. Physical assessment is important in my opinion. Even with x-ray, labs, CT, reliable notes etc. I know that my RN and MD coworkers as well as myself have caught things just by physical assessment alone. DVT's, dehissed wounds, fractures, etc. Even if all you glean from your physical assessment is that the patient just doesn't look right at least you know to keep a closer eye on them.
  16. Sugarcoma

    Intubation - confused about orders

    Roc takes 2 minutes for onset. Etomidate is 50-60 seconds with a duration of 3-5 minutes. I would be more worried about what was ordered for my patient following the intubation ie Fentanyl/Versed combo for comfort after the Etomidate wore off. Was Roc the only paralytic used? Some docs still use sux and will ask for a small (defasciculating dose that does not paralyze) of rocuronium prior to administration of sux. I have only seen this in ER though. Do not beat yourself up. Your new to this. You asked your coworkers for help. Sometimes the advice we get from coworkers is not always the best. I would definitely ask your charge what the rationale is for pushing the meds "exactly as the doctor said" just to get her input. Things happen so fast in the unit there is not always time to look things up. Spend your off time memorizing medications you use frequently. Many nurses make themselves "cheat sheets" with avg. dosages, onset, pharmacology, etc. they keep in their pockets or taped to the back of their badges for reference. It takes awhile between meds, hemodynamics, vents, and conditions to learn ICU. Remember there is nothing wrong with asking the docs why? I spent the first year in the unit saying "I'm new, why are we doing it like this"?