Blueorchid

Hello all, Bit of background history, I am a nurse with 5.5 years of ICU experience in a busy trauma ICU followed by 1.5 years of experience in the Cardiac Cath Lab. I switched to CCT ground in 2017 and October of this year will make it a full 2 years in CCT. I've been an EMT since 2008 and I am currently in year two of five for my AG-ACNP/CNS program. I have somewhat of a break in my classes (I had to stretch from a 4 year program to 5 to keep a roof over my head) and here is where I sit. I feel like I am going through a bit of what feels like a "midlife crisis" as far as my nursing is concerned (yes I know by many standards I am still a young nurse but I don't know how else to describe it...haha). When I started my DNP program I sort of resigned myself to the fact that I would not fly as a nurse which was okay for me at the time. Now that I've taken a Flight Bridge review course up in Ohio I know that there are such things as flight NPs (which seems pretty awesome and a potentially growing field) and I'm trying to figure out which exam to take. With three years left in my program I imagine there is a possibility for me to fly if the right position were to come up. As such, should I take the CFRN and have it under my belt as a cert? Or should I go with the CTRN with the understanding I might have to take the CFRN if I should happen to find myself with an opportunity to fly? Thanks in advance! Blue

Our multidisciplinary rounds consist of the critical care team with the attending physician, the fellow or resident, pharmacy, infectious diseases, nutrition, and respiratory therapy. Bedside nurses are expected to be present for rounds and you can spend anywhere from 5 minutes to half an hour discussing the patient's care (unless your patient is going to hell in a hand basket in which case you take care of your patient). You have to plan ahead for it, maybe you end up giving your medications at 9 o clock that are written on the computer at 10. Maybe you get the patient out of bed after they finish rounds at noon- it takes time but you'll find your own tricks. Since our patient ratio is 1:1 or 1:2 its nice to be able to sit down and discuss things with everyone, and depending on the attending (ours rotate) it really makes us feel like we have an impact on the decision making process. We use a system based process and look at the patient from top to bottom to make sure everything is covered. The resident/fellow is responsible for reporting to the attending so they assess their patients quickly before rounds to get a general picture and anything lifesaving or necessary can be addressed with them then. I also get report the same way rounds are delivered so it helps for a reference point if you're worried you're going to miss something. For example: Neuro: Is the patient receiving adequate sedation? Pain management? Are the neuro checks sufficient for your assessments? Do you need more or less? Are there any drains or output that need to be discussed like an IVC? Respiratory: What are the ventilator settings? Does the patient have thick secretions? Can they be extubated? What does their x-ray look like? Cardiovascular/IV lines: What does the patient's heart rate look like? Are there any ectopic beats? Do they need an EKG? Is the blood pressure adequate? Do they have enough IV access? What about their labs? Is their crit high enough or do they require any kind of products? What about electrolyte replacements? GI/GU: Can we feed the patient? What do we feed them? How do we feed them? Are their blood sugars okay? Do they have/need a Foley? Is their urine output adequate? Skin: Do they have any dressings? Is there any wound that we need to be concerned about? (Is there something infectious disease needs to look at because their white count is in the 40s and climbing?) Family/Social: Did you find something new about the patient's history? Did we give them blood and they're a Jehovah's witness? Did the wife recently bring in an advanced directive? Does the whole team need to address the family in a meeting? You're not going to know absolutely everything there is to know about a patient in the limited amount of time you have to look them over. Obviously the questions I riffed off are just a small portion. If you have a recent set of labs, print them at the beginning of the shift along with your med list. Get bedside report in the same manner you deliver it on rounds, go down the patient from head to toe and when you're done discussing and assessing think to yourself before you go on rounds "what can I get done with them today?" (that last part becomes routine once you feel more comfortable) Its a cool feeling when you find an issue with a patient that hasn't been addressed by anyone else, the docs at my hospital know we spend the most time with the patient so you wind up really having a say in your patient's treatment plan. Stick with it, it gets easier! And you wind up learning the most on day shift because once you come up with a treatment plan you're not 100% familiar with you can ask the people around you how things are done. Good luck! :)

"Hold my beer and watch this!"...yep ?

I had a similar experience when I was in nursing school (and a tech in the ED) to which I always hear the resounding words of my clinical instructor. You are the nurse and you protect your patient. Having just done an extreme dressing change I would question the need for the MRI BEFORE I went and did anything. Was there a concern about spinal cord compression? A mental status change? If he's moaning in pain I'm guessing he's not intubated or he's coherent enough to ask you to clean the blood off. Explain to the doc how much this is going to hurt in a patient who's likely still in shock (both from the hypovolemia related to the fractures and the fluid loss from being charbroiled). If his vitals were stable Im guessing they weren't after that dressing change (I would be tachycardic as all get out). Maybe a halfway point could be reached ie. if he needed the MRI for a neuro exam you could show the doc that he is oriented or possibly do a sensorimotor exam far faar away from the burns. Most of the time when you word it correctly the docs try and think of ways to work with you. If all else fails then you medicate medicate medicate. Friend of mine had an Assistant Vol FF Chief badly burned in a flashover. He had third degree to his arms and a good portion of his torso. To put pain meds into perspective this man was never intubated but cleaned the transport helicopter of its entire narc supply while they flew him to a regional burn center.

Updated: I took a deep breath and reported to my manager how my shift report was a load of BS. I put it nicely that I was concerned if she was getting an incomplete report from the OR that there might be a communication breakdown. I mean, what if the guy had herniated? Regardless, it was refreshing to hear someone else say the maturity on the unit is obscene at times. I don't know if anything was said but the nurse in question seemed rather pleasant to me as of recent. I'm still keeping my ears open. He said they were working on the clique part and that it will take some time, but it will get better. We'll see. Either way, the stubborn part of me does not want to be chased out of my job so Im gritting my teeth for now and looking for something potentially PRN. Its hard though when you love the complexity of a sick ICU patient (with that little childlike voice in my head giggling "I have so much to think about...yay!") as opposed to not knowing what's coming through the door and having to gogogo with a sick ED admission. Ah choices... Thanks for the support guys :) PS. EchoRN, its like a secret ambition of mine to do cardiac massage haha. I've only seen one cracked chest on our floor but plenty of thoracotomies. Maybe one day

Hahaha oooh I remember those days. My Med Surg instructor was the same way. We would go on the unit the day before our clinicals with our patient assignments, look up lab values, meds, medical history, and anything else pertinent and be expected to have it all recited the next day. And we would be quizzed for at least a half an hour. We also had to think of problems for these patients (at least 3) and what nursing interventions we would use to fix them. Listen, it really does make you a better nurse. You don't think it will now but there is a purpose to all this leg work because one day you'll be able to pick up on why the chronic drinker who fell with a head bleed requires a head and abdominal CT, why he's in four point restraints because he keeps trying to crawl out of bed and understand why his platelets and coagulopathy are crummy and need to be watched. And additionally why his serum ammonia is through the roof and you're giving him lactulose. Keep your head up and try and keep your answers short and sweet with the bulk of information you're expected to know. It is alot but sometimes it helps cut down on the time.

Reposted this here because I think I might get better responses. If that's a problem someone let me know :) This isn't the first time I've seen a thread like this but I would love to hear opinions from other people to get a better grasp on reality. Coming up on February of this year I will have been an ICU nurse for 2 years in an inner city trauma center. I started in the ICU as a new grad and prior to that had experience on the floor for an additional 1.5 years as a student/ student resident. When it comes to the patients I love what I do. There are days it's exhausting and draining and you can't wait for that next shift to come in and give report but I haven't had a day yet where I've gone "I wish I'd taken a job somewhere else." I also genuinely love being a nurse. Now, that is in reference to the patients themselves. My coworkers on the other hand are driving me up the wall. Last night I had a breakdown with a little cry in the report room so I didn't go out and blow up/scream at other people. I've been trying to make a concerted effort to take sicker patients as of late to challenge myself. And having spoken with several of the senior partners on my floor, nurses who have 20+ years of experience they agree that I'm ready and encourage me to use them as resources on the floor- which I already do. Unfortunately the days that those senior nurses aren't in the numbers or on the floor I feel like I'm at my wits end. I'll be the first to admit I'm not part of any clique on my floor and I'm not there to become best buddies with anyone, my job is to take care of the patient. That doesn't mean that I'm going around kicking someone who invites me to lunch but I honestly think it's more important to turn off the beeping IV channel first before sitting down to watch a movie on the computer. Having a string of three shifts in a row I'll just give a quick sample of the things I've run into where I swear I've backslided into high school. Report was given to me on a pedstruck admitted from the OR (who I was encouraged to take) where the nurse had absolutely no idea what was going on, no charting was documented, and all I had to do was check the patient with a head injury's pupils to see what she was telling me was a crock of s**t (cause are they supposed to be two different sizes?...hmmm). She then refused to take the patient back the next day because she told the rest of the shift she was there until 8PM doing work (while she was chatting with three other nurses as I stood at the door and asked for a glucometer and a clean draw sheet). I managed to keep said patient from going on dialysis with myoglobins in the 11,000s, monitored ICPs, drain output from a broken pelvis, Grade II liver, and IVC, drew labs, started him on insulin, kept his temperature normothermic, took him for a repeat CT scan, supported the mother, father, and wife, along with the 10,000 other family members that came in to see him and then some and when people asked if I needed help and I mentioned simple things like "could you help me turn" and "could you go get this" I was refused. The next day after spending an hour scrubbing him down during his bath (he was covered in blood) the family complained because there were still dried flecks on his hands. Granted, when I asked for help, the people who were supposed to serve as "resources" were nowhere to be found. I did the best that I could in the time I had. The third day with said patient after coaxing pharmacy to send me a medication that was several hours late I notice another patient on the floor has a kangaroo pump that's beeping empty because the tube feedings are done. His nurse is nowhere to be found and the patient's brother keeps coming to me because I'm the only nurse on that side not eating pizza and Chinese food. Instead of changing the patient's bag I turned the pump off and made sure that he wasn't on insulin before tossing a word down to the nurse and going back to my own work. I get reamed out for not doing additional work to help him when I'm busy as it is with my own combo. Another nurse who had the same combo (and is in a similar situation- we'll call her Lucy) was going to be reprimanded by her charge nurse that day because she resourced another nurse to help her second patient while dealing with this sick guy. The other nurses? They were watching a football game. But that was "over-delegating". Now I'm being told by Lucy that I should report the things Ive been seeing to my nurse manager since they're apparently reporting crap about me (I wouldn't be surprised if I heard that when this patient was admitted the nurse I received report from was there for hours helping me because I couldn't handle things- which is a flat out lie.) But throughout all of this Im thinking "really?" Has it come down to me tattling on one nurse because she'll do the same to me and more? I've had my ups and downs with my coworkers- the first year I took it really hard when I clashed with different personalities, the second year I decided to start standing up for myself. However now with standing up for myself and a desire to take things further and learn I feel like this lack of support is going to hold me back. Because Im not a part of the "in-crowd" whenever I ask for a challenge Im going to be treading water on my own and it makes me worried my patient care is going to suffer. This begs the question should I find another place to continue learning? I don't want to leave the ICU/critical care setting and my heart has always belonged in the ED, but Im wondering if this culture is just specific to that area or if there exists a place where people can work together for a common goal and get their heads out of their rectal cavities? I also know jobs are still hard to come by, how long do I have to stick this out? Replies are welcome. Thanks!

I knew an old Neuro ICU nurse who swore by Frank Sinatra for her really sick heads. She said the tones decreased their ICPs. I think there's benefit for both the nurse and the patient so I'll frequently put on AOL Radio at night and turn the volume up on our bedside computers accordingly when Im giving baths or doing something that requires me to be in the room for a longer period of time. During the daytime I usually ask the patient's family members what kind of music they like listening to and so long as its not death metal or really bad gangsta rap I'll see what I can do. We also have Music Therapy that can be requested if the doc puts in an order for CAM (contemporary alternative medicine/modalities). Its somewhat like a request for a bundle where you can get music (guitar, harp, cello), reiki, and a few other things. I look forward to the day when that includes pet therapy :)

This isn't the first time I've seen a thread like this but I would love to hear opinions from other people to get a better grasp on reality. Coming up on February of this year I will have been an ICU nurse for 2 years in an inner city trauma center. I started in the ICU as a new grad and prior to that had experience on the floor for an additional 1.5 years as a student/ student resident. When it comes to the patients I love what I do. There are days it's exhausting and draining and you can't wait for that next shift to come in and give report but I haven't had a day yet where I've gone "I wish I'd taken a job somewhere else." I also genuinely love being a nurse. Now, that is in reference to the patients themselves. My coworkers on the other hand are driving me up the wall. Last night I had a breakdown with a little cry in the report room so I didn't go out and blow up/scream at other people. I've been trying to make a concerted effort to take sicker patients as of late to challenge myself. And having spoken with several of the senior partners on my floor, nurses who have 20+ years of experience they agree that I'm ready and encourage me to use them as resources on the floor- which I already do. Unfortunately the days that those senior nurses aren't in the numbers or on the floor I feel like I'm at my wits end. I'll be the first to admit I'm not part of any clique on my floor and I'm not there to become best buddies with anyone, my job is to take care of the patient. That doesn't mean that I'm going around kicking someone who invites me to lunch but I honestly think it's more important to turn off the beeping IV channel first before sitting down to watch a movie on the computer. Having a string of three shifts in a row I'll just give a quick sample of the things I've run into where I swear I've backslided into high school. Report was given to me on a pedstruck admitted from the OR (who I was encouraged to take) where the nurse had absolutely no idea what was going on, no charting was documented, and all I had to do was check the patient with a head injury's pupils to see what she was telling me was a crock of s**t (cause are they supposed to be two different sizes?...hmmm). She then refused to take the patient back the next day because she told the rest of the shift she was there until 8PM doing work (while she was chatting with three other nurses as I stood at the door and asked for a glucometer and a clean draw sheet). I managed to keep said patient from going on dialysis with myoglobins in the 11,000s, monitored ICPs, drain output from a broken pelvis, Grade II liver, and IVC, drew labs, started him on insulin, kept his temperature normothermic, took him for a repeat CT scan, supported the mother, father, and wife, along with the 10,000 other family members that came in to see him and then some and when people asked if I needed help and I mentioned simple things like "could you help me turn" and "could you go get this" I was refused. The next day after spending an hour scrubbing him down during his bath (he was covered in blood) the family complained because there were still dried flecks on his hands. Granted, when I asked for help, the people who were supposed to serve as "resources" were nowhere to be found. I did the best that I could in the time I had. The third day with said patient after coaxing pharmacy to send me a medication that was several hours late I notice another patient on the floor has a kangaroo pump that's beeping empty because the tube feedings are done. His nurse is nowhere to be found and the patient's brother keeps coming to me because I'm the only nurse on that side not eating pizza and Chinese food. Instead of changing the patient's bag I turned the pump off and made sure that he wasn't on insulin before tossing a word down to the nurse and going back to my own work. I get reamed out for not doing additional work to help him when I'm busy as it is with my own combo. Another nurse who had the same combo (and is in a similar situation- we'll call her Lucy) was going to be reprimanded by her charge nurse that day because she resourced another nurse to help her second patient while dealing with this sick guy. The other nurses? They were watching a football game. But that was "over-delegating". Now I'm being told by Lucy that I should report the things Ive been seeing to my nurse manager since they're apparently reporting crap about me (I wouldn't be surprised if I heard that when this patient was admitted the nurse I received report from was there for hours helping me because I couldn't handle things- which is a flat out lie.) But throughout all of this Im thinking "really?" Has it come down to me tattling on one nurse because she'll do the same to me and more? I've had my ups and downs with my coworkers- the first year I took it really hard when I clashed with different personalities, the second year I've decided to start standing up for myself. However now with standing up for myself and a desire to take things further and learn I feel like this lack of support is going to hold me back. Because Im not a part of the "in-crowd" whenever I ask for a challenge Im going to be treading water on my own and it makes me worried my patient care is going to suffer. This begs the question should I find another place to continue learning? I don't want to leave the ICU/critical care setting and my heart has always belonged in the ED, but Im wondering if this culture is just specific to that area or if there exists a place where people can work together for a common goal and get their heads out of their rectal cavities? I also know jobs are still hard to come by, if this is what Im stuck with how long do I have to stick this out? Replies are welcome. Thanks!

A slight reversal of the situation. As a new grad on a busy ICU floor, I had the pleasure of dealing with a nurse for the first 4 months or so off orientation who would go out of her way to tell me each and every thing I did wrong. She would pick over my charting with a fine tooth comb (despite the fact that when I looked back at her notes I found things missing that she would yell at me over), and on special occasions would take the time to insult me in front of patients who were awake and oriented, or extubated and completely conscious. Don't get me wrong, I learn from my mistakes (and I end up being a better nurse for it) but the way she "taught" was terrible- if she even called it teaching. At one point, after taking report from her on night shift, with two days in a row of the same shebang I'd had enough. My patient could clearly see I was upset (and I was doing my best to hide it from him). He had a huge soft tissue infection that had gone down to the fascia and in some places the bone of his right leg (it later moved to his left...ah vibrio...) His response after hearing everything she said? "Actually I thought you were one of the better nurses Ive had up here." I took a deep breath and said while she had a right to an opinion, I tried to learn from everything people taught me and that I wasn't going to let it get to me. (Can you feel the PR coming from that response?) His rebuttal? "And you know what else? Opinions are like *******s, everyone has one" The first comment made me smile, the next one had us both laughing. He eventually passed away but every once and a while I still think about him.

Well, to all those who wanted to know everything came back negative :) :) :) After an unpleasant weekend wondering what to do next I went down to employee health and was told I was extremely low risk for any kind of transmission in the future. I'm still going to get tested for peace of mind but for now I'm going to put it out of my head. Thanks everyone for the well wishes. I consider this one my "freebie" and will try to be more careful next time. -Blue

Never one to do things halfway- the second night off orientation I manage to stick myself with a 21 G butterfly needle. I was drawing an ABG on a patient that required multiple measures of sedation- he'd had Haldol, Ativan, and I'd been watching my Precedex gtt with a tech at the bedside holding his leg as a final safety measure. Of course the first two times I feel the pulse and he doesn't move- we're short on staff that night so when the tech is called for a transport I look at prioritizing and give him the chance to leave...the guy hasn't been moving right? Wrong! Third time's the charm. I'd gone into the skin, pulled back to the point that the needle tip was just under the skin when this guy kicks his foot straight up and I fall forward to catch myself. The needle goes back through his skin and nicks mine. (And I was wearing gloves!) I'd never drawn a flash- I bled the wound as soon as I saw it and washed my hands multiple times before talking to my charge nurse. Blood has been drawn, consent was given, and so far I know he's HIV negative. But the guy has been incarcerated multiple times before and has lots of tattoos. I get to find the results for Hep C on Monday but I already feel like he's high risk. Any ideas on whether or not they would encourage me to take the meds anyways? This is terrible. Everyone on my floor who found out has been super nice. I've even talked with someone who took meds for a HIV positive patient and she's offered to help if I need it. But I think the worst part is the waiting. I called my boyfriend at 8 this morning and burst into tears at a coffee shop when it all finally hit me. I'm really easy at thinking worst case scenario. He's HIV negative but I could still convert...and the guy has a lot of risk factors but I know I don't know anything for sure. And I haven't told my parents yet because I want to wait till Monday, I know how they get and I don't want my mom to go around lamenting that her daughter's going to die- they have enough on their plates as is. Needless to say it sucks. Support would be greatly appreciated and any advice/opinions as well. Thanks.

Amen, Our unit is going through something very similar with a patient right now and siblings that just can't seem to get it together. Meanwhile this poor woman is slowly melting into a hospital bed. The plus side is that the attendings have absolutely refused to withhold pain medication at the daughter's request because "she's getting better." But she's being transferred to another hospital like a car going to a new auto-shop because they're still holding out for something. Regardless, sometimes I just want to pull the family into the room and make them do nursing care so they realize what kind of life she's going to have until something finally takes her. If you're keeping someone alive for whatever reasons you might have then you don't get to leave when you're upset by a dressing change or procedure. You need to know everything about the life you're now responsible for and if we've explained that we've done everything we can you also need to realize everything is not always about you.

Oh boy get ready to learn a ton! I was that ER tech with a little bit of experience in the middle of nursing school. Best get a good pair of running shoes because you will be doing alot of work :) Flying Scot hit the nail on the head. Sometimes the ER can be short staffed. Sometimes they go on alert and sometimes they reroute people to other ERs because it can get so busy. And sometimes, though not very often I hope, you will be the only tech on the floor bouncing from place to place. Saying "no" to a nurse asking you to get ice for room 15 because you're updating facebook is a bad idea. "Can it wait a minute? I need to do an EKG and start an IV in room 12" works much better. Get to know the people in your ER...the IV queen, the calm collected soul who can calm down the raging psych patient, the one who can always drop an NG tube, and many others. Everyone has their own skill. Oh and be sure to watch any procedures you can, fit yourself into that corner. Find the nurses who love to teach but know everyone can teach you something regardless. You'll be surprised when you get into MedSurg and read a patient scenario off of a powerpoint going "I saw that guy last week!"

Didn't really know where to put this since its trauma related. But! Had a patient a few days ago with a Grade III liver injury, MVC that was ped struck and her organs took a hit from the aftermath. She was suspected of having heparin induced thrombocytopenia and was started on Argatroban by the chief of basically the whole hospital. Said lady had a fever which wasn't really high grade but was enough that I wanted to get it under control. She had a bunch of ortho traumas, on the vent, figure the last thing she needed was something growing to give her an infection. And I was with a brand new preceptor (I needed to do an extra day) who was vehemently against me giving Tylenol. Her rationale of course was the Grade III liver. Now I get that Tylenol is metabolized through the liver so I understand why, but Argatroban is too. I wasn't on rounds when it was chosen as the HIT drug of choice (because looking at this I wonder if we could have used a different one) but if she was on Argatroban would it really be that much more damaging to bring her fever down with Tylenol? For the record I hate thinking of things in hindsight...my goal one day is to be able to pipe up with this during the actual rounds but Im getting there