PICURN74

There are "National Patient Safety Goals" that might give you some insight

Can't speak for Texas or give legal advice but in my opinion you are right to have some concern. I think you bring up a good point of the level of consciousness being deeper than traditionally considered "moderate" but also concerning is that many of the recommendations for "best practices" related to sedation include having the person responsible for providing sedation be separate from the person performing the procedure. I couldn't tell what the practice at your location is. I agree with you that nurses can often handle situations that arise but make sure that you are supported by your hospital if things go bad. Keep questioning until you get your answers, preferably in writing.

There are a couple of thoughts I have on the situation, SNS stimulation releases Epinephrine and Norepinephrine as well as cortisol and aldosterone etc. and causes the effects previously mentioned, in doing so it decreases blood flow to the kidneys (need the blood else where) which causes decreased urine production. Your kidneys don't like this and so they deal the best they can (since you still need to fight or flee they can't over ride the sns) and decreasing the pressure in the bladder makes the little blood getting to the kidney easier to pass into the kidneys (still keep some kidney function) also nor/epi cause smooth muscle contraction (hence the vasoconstriction) so you get some contraction of the bladder as it is also a smooth muscle so you feel the need to go. Just my thoughts

I agree with everyone else your feelings are normal but that doesn't make them easier. I also work in the PICU and pediatric codes are especially hard as a general rule kids are not suppose to die. I don't think you get used to them but rather learn to cope and see them differently. I used to second guess myself and wonder if I were more expierenced if the outcome would have been different but as I have seen more codes I have learned that as much as we want to control things somethings are out of our hands. Some kids recover dispite our mistakes and some sucum despite our most heroic efforts. The serenity prayer/chant helps me "...grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference" Wisdome and serenity came for me later and I can tell you already have the courage part down

Be honest with your desire and your areas you need to improve. I tell my new grad orientees in the PICU that you aren't suppose to know everything on day one or orientation would be pointless. To me the more important quality in a good ICU nurse is desire to learn and genuine motivation/interest in the positon which you sound like you have.

you might want to try craigslist for an instructor, I have had some friends who were able to find someone this way to validate skills after doing the online portion. Otherwise try calling the boyscouts/girl scouts they sometimes have classes or know instructors (just besure to find a healthcare provider course) Local YMCAs sometimes are good places too.

The best gift I got was a box of my favorite pens (my personal favorite is Pilot ultrafine point) I never knew how much the quality of your pen can affect the quality of your day until I started in the Unit. Otherwise coffee is always a crowd pleaser.

FutureNICU- You are suppose to be scared of codes they are one of the few things that are literally a matter of life or death. You will learn to use the fear and it does decrease but they day that a dying kid ( I work in PICU) doesn't scare me a little is the day I will hang up my stethoscope. During a code I am usually fairly calm and then afterwards is when I notice my heartbeat in my throat and how fast I am breathing. I have broken many ribs and those that have survived haven't held it against me.

You made a mistake and you admitted it now you need to forgive yourself for it. It will be something that is with you for quite some time but doesn't have to mean the end of your career let alone your life. While every situation is different, I work in substance abuse where I see people who make mistakes time and time again and eventually put their life back together. We even have some recovering addicts who work in patient care. It will be a long road but stick to it, get thick skin and keep trying and you will be the one who determines your future. Hang in there.

Check with your institution but, vistaril can be given IV but it is often avoided if possible, however it is on my formulary as IV and I have had some patients recieve IV vistaril.

Glad to hear your son pulled through! Where I work we have a general hospital wide orientation followed but nursing specific orientation when we first get hired and then we are given additional instruction throughout our employment. One of the things that I found really helpful when I first started was hearing what it is like to be a parent in the ICU. We have something called patient family advocates, mostly parents of former patients or current long term patients, that are actually on staff and that tell their stories, answer questions and give suggestions to new nurses, doctors and other members of the health care team. They are also available to talk to families that are currently going through it because it is nice to talk to someone who has been in their shoes. I know the families and staff love it.

TallTraveler- Unfortunately we see many kids like this (motorbikes should be illegal but I digress) Is the patient in traction or in a C-collar? Depending on the reasons for the immobilization, our doctors sometimes will allow us to put the bed in reverse trandelenburg (Pt is still flat and immobile just changes the vantage point) but that is on our crazy expensive ICU beds that have lots of bells and whistles. Depending on how old the pt is we will often put the younger ones in a bubble top crib with a clear plastic top and place things on top of the plastic (DVD players from Childlife or mirrors/toys) but the cribs are designed in such a way that there is no possibility of the object falling on the kid. Sometimes we have light show machines (think planetarium/disco ball) that provide something to look at. Also books on tape/cd can provide some relief and are available at most public libraries (kids seem to be mad if they listen to DVDs while everyone else gets to watch them) Hope something helps

The scale is 3-15 with extremes at both ends. In our facility 10 and below is a sure way to get the million dollar workup http://www.trauma.org/archive/scores/gcs.html

I agree, mistakes are just that until you try and cover them up then they become choices be honest. It sounds like you did try and varify the dose after reading it back to the doc and checking with pharm. In my world I sometimes give crazy doses of drugs but I still double check with my neighbors/docs. It could have been the doc forgot what they ordered when they went to read it in the chart. When we take a verbal order we have a big yellow sticker we place in the chart where we write what the doctor says and that we wrote, repeated and varified the order and sign it and the doctor then comes and cosigns the order. Most importantly the patient sounds like they were not harmed and pain was treated.

I work in peds and do a lot of lifting, best advice is find a job you will love and figure out a way to deal with the rest. Making friends with the stronger people on the unit is always a good idea (I am 6'4 and have a LOT of friends come time to change/transfer patients) there is strength in numbers (save your back)

I will take a new nurse that asks a million questions over one that thinks they know everything anyday. If you don't know ASK ASK ASK. You are not expected to know everything otherwise orientation would be pointless. I still ask questions just about every shift and I precept new nurses. The first day I am with my new orientee I always tell them two things, Don't ever be afraid to ask anything there are no stupid questions(esp on orientation) and no matter what the question is AIRWAY is always a correct answer;).

I don't care what mistake you make, Screaming at people is never ok. I agree that you should confront the situation, talk with the people you are having a problem with if you can and then work your way up the ladder NM, HR whomever it takes. Hang in there!

Kitty- Sounds like a pretty bad first expierence sorry your first post graduation nursing experience was negative. I am curious who repeatedly told you never to say anything about a nurse? I agree that as a whole our profession has a problem with gossip and talking about people can lead to issues but I don't care what your job title is if you are doing something dangerous I am going to say something. It isn't your place to be a manager so I wouldn't expect you to have to confront your preceptor but you can always tell someone your concerns, as a general rule I try and talk to the person I have a problem with first (nurse, doctor, CNA whoever) It takes time to get confidence to do that (esp doctors and more senior nurses) but if done correctly it shouldn't matter who points out the errors as long as it is done with respect and handled appropriately. Otherwise you can always confide in a charge nurse or NM and they can deal with issues through the proper channels. Unfortunately it sounds like you feel your NM dropped the ball. Sometimes working with people you wouldn't choose to hang out with after work is part of the job and I believe you can learn a lot from people you don't get a long with but it sounds like you tried to make things work and when they didn't repeatedly tried to change them. I hope your next job is a better fit and you feel more support than you did at this job. You should always feel like you can report unsafe situations even if it is annonymously. Good luck and hang in there you will find your "right fit"

I agree with the above posters, Learn from your mistake and forgive yourself. We are all human and we all make mistakes, fortunately it sounds like your patient was spared any significant harm and I am sure you will be a freak about checking your pumps from now on because of it.

I am a little confused too, I am hoping that not knowing there was a change in the patients condition was what upset the doc. I have never seen a MD order an IR, at my facility IRs are not punitive but a chance to prevent future incidents, also we don't mention them in pt's chart but that is between you and your legal department. I have seen pts on HFNC on more than 11L flow but it is a pretty significant requirment and with the hx of resp failure I would have been a little concerned they were going to need to be intubated. Our RTs are amazing and are often my first call when my kid looks funny but I find you have to be specific in what you ask, for instance I specify my kid is changing tell me what you think about them versus can you check my equipment (sometimes I ask them both in the same shift)

I would talk to the supervisor about the things you have seen and then either promise yourself to do what you know is right not what your preceptors are doing or start looking for a new job. An expierenced nurse can be an awful nurse and a new grad on first day off orientation could be the best nurse on the unit. It is evident that you know the most important things about nursing, keeping patients safe.

as a general rule follow the abcs, not know anything about your patient i don't want to give you specific advice but personally i would check airway (assume trach) is patent (a), then breathing (b) personally in code/cpr situations bmv is my first choice and then © compressions. depending on who you are certified in cpr through there may be variation. aha's new recomendations just changed for cpr for single rescuers to be compressions only as people were taking too long to give breathes but with more than one professional rescuer breathing is still in the protocol.

Every lab is different but when I worked in the lab I used to tell people when in doubt draw red and get it to the lab asap. The color of the tube usually is related to the additive in the tube that affects the sample. Red tops typically are whole blood (no additive) meaning the lab can usually transfer blood to other types of tubes if the specimen hasn't clotted. We also draw coags first (blue) and for the most part Green/gold/tiger top are fairly interchangable although your lab might disagree (they all are serum seperators) and most chemistry labs can be done on serum.

I agree with what everyone else said, learn from the expierence and dust yourself off you will be a better nurse for it. Nursing is a second career for me and while I was in school for my first degree I failed out and was mortified. I applied and got back in on probation and went on to graduate, after which I got accepted to an Ivy league nursing school and now work in a PICU while working on my masters and love every minute of it. Everyone has struggles in life it is how you deal with those struggles that will determine what kind of nurse you will be

Sunbird- I agree you need to have something change in your orientation because it does not seem like a learning environment. As a preceptor let me tell you that orientees often feel they are drowning when they are infact doing fine. A good preceptor will let you learn by doing but will not let you drown, it should be supportive and constructive. PALS is what I would take first but I also took ACLS and have used knowledge from both.