picurn10

we've had more than a few pts on ECMO who were so unstable, or their cannulas were so precarious, that we didn't turn at all, but its more typical to have to do small turns because they are unstable. We don't seem to have one set standard for our kids. We have some pads that have a moldable putty inside, we use gel pads, mepilex, and specialty beds on the bigger kids. We use this stuff inside our radiant warmers for newborns.

why not do trophic feeds and keep them on TPN until they're term, or closer to term?

I agree that it is often the boyfriend, but we've had several recently (and my most traumatic case) where it was mom. That case was so chilling because we did the first brain death exam, and afterward she just asked me for some washcloths, got into her pj's, and slept peacefully all night long. Do you guys see many arrests on your cases? I feel like more often than not, they get away with it.

Thanks, everyone. It really makes me feel better to read your responses.

see, our unit NEVER bans the family. I hate it! They say winter, particularly christmastime is busiest time for it. I've also heard the economy is leading to a rise in abuse lately

It's always the little moments for me. When you can tell you've made a difference for someone. Certainly after a code or a hard fight to save someone. Or even a meaningful end of life case. One that stands out was a baby I had for two straight weekends. He was super sick. On ECMO and CRRT. He was bleeding from everywhere and just looked miserable. We all thought he was going to die. I talked to him all night like I do all my pts, but he was intubated and paralyzed and sedated so not responsive to me at all. Anyway, a couple weeks passed and he recovered! I got to see him the day before he went to the floor. He was in a little hospital gown laying in the crib with no 02 or lines or anything! He looked at me, and gave me the biggest smile ever! I asked his mom if I could pick him up and when I did he laid his little head on my shoulder and just sort of melted into me. It was the sweetest thing. I 'know' he didn't have a clue who I was, but I felt like he recognized me and was like 'hey, thanks for taking care of me" It was priceless. I love my job!

I floated to NICU and my pt got NEC and likely won't survive. I have to float to NICU frequently (usually once a month) but we typically get feeder/growers assigned to us. I feel like I caught the symptoms early, but OMG, it was lightning fast and really sort of shocked me! I don't shock easy and have had pts go south quickly in PICU, but this was like: healthy/stable baby, to dying in just a couple of hours! I don't think I 'missed' anything, but I can't stop worrying maybe if I'd caught it just a bit sooner, her outcome would be different. The only symptoms started in the afternoon: a little tachy (she'd been 160-170's all day, and jumped to 180's) and her belly was starting to become distended. She was stooling, active bs, not tachypnic, she was on 21% @ 1L and sat'ing 100% all day. Normothermic all day. She'd just had 2-2.5ml residual before feeds and then when she got symptomatic it was 6mls. By the time I left she was on an oscillator, had a picc and working on an artline, and putting in drains at the bedside. I gave prbc's and ffp, and had orders for cryo, and more prbc's. Her gases were crap. They were about to start pressors. What kinds of things do you see before they get NEC? What might I have missed? I've taken care of all kinds of awful stuff (kids beaten into a coma, drowning, heart surgery kids, traumas...) but this has me rattled

my thought is that these hospitals with a focus on customer service need to have a pt consierge! They could run around fluffing pillows, bringing ice to pts, snacks to families, and all manner of butt kissing so that I can be free to actually provide the nursing skills I went to school for, the ones that are keeping my pts alive and healthy! Ah, one can dream, right?

wow, that RN tracking thing is INSANE! I think I'd quit at that point. Turnover in our unit is super high as it is. interesting to know that other places do this as well, I though it might just be my director's idea. Sarakjp, I know! huge pet peeve of mine when family with a stable kid get all ****** when you don't come running to fluff a pillow, when your other pt is crashing or some other urgent need. Our unit clerks are also tele monitors so they can't answer lights, but its a small unit and honestly pretty rare for lights to go off. We maybe have one or two a shift, sometimes none. I'm sure this was generated by a pt complaint. What's really irritating is that nursing staff wasn't told about it, just the monitor techs. So basically they are supposed to be ratting us our to our boss and we've never even been told 'hey, we've had complaints about call lights going unasnwered'.

I always knew I wanted to do ICU and work with kids. I thought I wanted to do NICU, until I had clinicals and realized there wouldn't be much variety (NICU babies seem to have the same set of problems). I LOVE what I do because I never know what I'm going to get, I can have a newborn or an 18yr old, a DKA or a gunshot victim, I really like the autonomy that comes with ICU and the stress of it. I love helping families through such a difficult time, and especially seeing a really, really sick kid recover! I have to float to NICU from time to time, and I know I made the right decision for me, but its fun that I sometimes get to dabble in that world too. Not sure I will always be in PICU, but I have no idea what else I'd like to do. Honestly, the plan is to become a NP and work in a peds clinic when I get tired of the stress and bedside thing.

Any one else dealing with this at their hospital? We were told that our call lights were being audited from now on. In ICU we rarely have call lights (we're typically in the pts room or very close by, and the pts can't usually use them). Now anytime a call light goes off, the unit clerk is supposed to visually locate the nurse and make a note of what he/she was doing when the call light went off and where they were in the unit. I'm trying not to be irate about this, but I'm having a very, very hard time with it. The whole point of using a call light is that your nurse is not in the room, right? So basically we're going to be reprimanded if we have too many call lights during a shift. Management believes we should either be in our pts room or directly outside their door at all times during a 12-hr shift. We don't have enough computers to chart outside our rooms so we typically chart in the nurses station in the middle of the unit. Anyone else encounter this?

our hospital's NICU just picked black for their scrub color and I was shocked! It seems like such a harsh, non-kid friendly color. Honestly, there is tons of research into colors and public perception and even specifically when working with kids. I'm really surprised hospitals haven't weighed in, but just let the staff pick the color.

In the ICU, everyone can typically handle high acuity. If the pt is just a train-wreck from the get go, they will typically reassign the nurse's first pt to someone else so that nurse only has one pt, or the charge nurse ask us to help take care of pt 1so the nurse can focus on the new, very sick pt. If it were a total newbie, then the charge nurse would likely reassign one of the more experienced nurses pts so he/she could take the really sick pt, and the newbie could have two low acuity pts. But ICU we only have two pts assignments, so its not too much of a juggling act most of the time.

hmmm, that sounds terrible. Our physicians write an order and a paper order prints, and an electronic copy is sent to pharmacy. At most it takes 10mins for it to show on the emar and the pyxis. If its longer than that, I just call to pharmacy and they fix it while I'm on the phone. Cancelled orders show up the same way, except that they fall off the emar, and you can see it at the bottom of the screen in yellow as a "d/c'd med" If you try to scan the med, it will give you a pop up that its been d/c'd. The stuff your describing sounds more dangerous than papers mars!

In my unit we typically have one nurse "open for an admit", meaning one actual assignment, and one empty bed. They don't actually decide which room until there is a pt on the way, but its near the nurses other pt. I'm in ICU though, so that may be different from floor nursing.

Sorry if my post came across that I was offened, not at all! I was just explaining why we can't pick up many of the pts. The more feedback I'm reading here, the more I realize it is unreasonable to weight them every day.

yes, bedside report is part of the "customer service model" that is proving to have dangerous pt outcomes, but because they government and insurance companies are starting to reimbure on "pt satisfaction scores" (the biggest load of bs ever) we're going to see more and more of this junk. We are supposed to be doing this, very rarely do we comply. For me personally, I am a very visual learner and am almost handicapped with auditory information. I HAVE to write down report, see the charts, see the labs, read the kardex and then I have a good handle on the situation and can give the best care to my pts. I don't want to be inturrupted while I'm gathering the information I need. What happens when we go bedside is the family asks for a million little things: cup of coffee, when can we order breakfast, can you get me another pillow... constantly inturrupting report, breaking the train of thought of the offgoing nurse, and I feel that really puts us at risk to leave out vital info. Research shows that poor communication is very often a factor in sentinel events, and this is creating poor communication IMO. We do a system by system report outside the room. Working with peds, more often than not there are relavent social issues that can't be discussed bedside. Then we go in and do our required introduction, then we check drips, trace lines, look at wounds/drsg, and give the family a quick update about the plan for the day and ask if they have quetions. A lot of families are scared and confused by what we're discussing in report. Its pointless to do it in from of them IMO. I do like the aspects of discussing their care plan and ask the family if they have questions, but actual report in front of kids and families is stupid. Of course no one ever asks nurses

babybluenurse, how do you lift a 50kg intubated pt w/ ct's, drains, on CRRT, or whatever the case may be? We have kids from 0-21yr and so other than a sling scale there isn't a way to lift them up. We have some pretty big kids too. I had a 85kg 9yr old a few weeks ago! What about a burn pt who is in terrrible pain, just w/ turning? I would never want to pick them up, even if I could do it. Our hospital also does a weight just post op, but we're expected to get a weight on admit to the unit from PACU (just a few hours later) and then if they admitted during the day, sometime later that night they want the "daily weight" done.

lol, I didn't pick up on the "snot" vibe, but apology accepted :)

dont always defer to "more experience" or "the expert" when you feel like something's wrong. I had a situation not too long ago where this was highlighted: Both the attending and two residents incorrectly assessed the situation, but I knew I was right about it and kept harping on it until they took a second look. Lo and behold, I was right! This pt went immediately to surgery and I really believe my insistence either saved her life, or made her recovery time much, much better. Six months ago, I would have talked myself out of what I knew was "off" because three different doctors were not seeing what I was seeing. I'm so glad I didn't just defer to them.

lol, I do understand the concept of zero'ing a bed Ashley is gettting what I'm saying. So, day 1 the pt bed is zero'd w/ a sheet and one pillow. No one writes down what was on the bed. Day three I come in to weigh the pt and now there are 15 pillows on the bed, five blankets and two sheets. Because I don't know what was on the bed day one when it was zero'd, the only way to get an accurate weight is to get out the sling scale (usually at 2am) and get the intubated/lined out pt up off the bed so I can rezero it. Ideally, if the bed was zero'd day one, I shouldn't have to rezero it, just push the weigh buttons on the bed. In the short term the solution is for people to keep better records of how the bed was zero'd, but ultimately it comes down to how much risk/pain/stress we put the pt through to have that daily weight.

there is a really cool poster out there somewhere (we have them in our hospital but I've seen it online) that shows the difference on the hub under the bioluminecent light at 5, 10, and 15 seconds of scrubing. Its a great visual. I have read recently that the standard for central lines and piccs is 30 seconds. Even though my hospital only requires 15, I go the whole 30. I force myself to count every single time, never guess. I'm not going to be the one who gives a pt a central line infection if I can help it!

I'm sorry but you have the pathophys on this all wrong! We aren't worried about stroke from air in the line, we're concerned about air embolism. This can be caused by a pocket of air entering the right atrium/ventricle (prior to making it to the lungs) and either completely obstructing the blood flow to the lungs, and then subsequently the rest of the body, or lodging itself in the heart/lungs/brain of a pt. The "bubble" of air (and really its more a bolus than a bubble) can cause fatal arrhythmias even if it doesn't block off blood flow. The increased PA pressure created by an air bubble in the right side of the heart shuts off flow because the hearts circulation requires certain pressure gradients to function properly. Yes, the capillaries in the lungs can filter some of this, but it can also cause pulmonary edema from the excess pressure forcing the blood into the capillary beds and permanently damaging them. It is true that the small bubbles in IV lines aren't enough to cause it, basically the entire IV tubing would have to be nothing but air to cause it in an adult PIV, but if you are using a central line or talking about a child, its far less air to cause a fatal rhythm or air embolism. Some documented cased with as little as 5ml causing problems in central lines. That said, I don't worry about the little bubbles at all. If I've primed my tubing and there are some bubbles, I don't think twice. The other night I primed NS for what looked like was going to be rapid IV boluses to prevent my pt from crashing (pressures dropped from 110's to 50's in like 45sec) and I connected it to her PIV. I didn't give them because she came around on her own, but my charge nurse looked at my line (with less than two inches of air at the end) and said "well she didn't code but she would have if you infused that". I didn't argue with her at the time, but I knew she was wrong, because its sort of nursing "urban legend" that small bubbles of air will kill a pt. That portion of the line was maybe 1/2ml, and it was going to a PIV. Not losing any sleep over that one! I have found that priming slowly makes all the difference. Once I started slowing down, I never had an issue with excessive bubbling. Sorry for any spelling errors, I can't figure out how to get my spell check to work :)

Very interesting to have the other perspectives, thanks! Janfrn, just to be clear, I do understand how zero'ing works Our problem is that often the nurse zero'ing the empty bed forgets to list what it was zero'd with, so then as the days pass and more and more stuff winds up on the bed, there is no way to know how to clear the bed to get an accurate wt. Was there one pad or two? a flat sheet and a blanket, or just a sheet? and so on... Then you have to get the pt onto the sling scale just because no one bothered to write down how the bed was zero'd, we don't have a policy in place that says always zero with xyx, or something like that. I just feel like its an out of date policy that causes major upset and headache to the families/pts/nursing for no reason. You all have confirmed my "hunch", now I just need to hunt down some research on the subject if there is any.

how does your unit handle weighing pts? Our standing policy is daily weights for all pts. We have about half our beds that actually have scales, for all the rest we have to put the pt in a sling scale. It can be painful for the pt and dangerous in my opinion. Occasionally I've refused to use the sling scale on a pt when I felt it was too dangerous. We routinely have pts come back from the OR on a non-weighing bed and are expected to get them into the sling scale. What frustrates me is that we do strict I/O on every pt, and we DO NOT use the new daily weight to adjust drips. I've yet to get a straight answer on why we get weights if we aren't going to use them. When writing orders the md's use the admit weight only. Sure you can glance at the weight at see if there was a big gain or loss overnight, but you can do the exact same by looking at the I/O for the 24h, right? That seems more accurate to me than the weight anyway, because I don't believe that other nurses always pay attention to what the bed was zero'd with to begin with. I know its a big source of frustration for staff because the lack of weighing beds/kids being forced to use the sling scale is upsetting to pts and families. We've had numerous unplanned extubations during weighing too. What does your unit do? Do you use the weight to recalculate gtts or for new orders?