gal220RN

I have had some questions burning in my mind over the past few months and would love some input from my PICU friends. Since I changed jobs to a PICU with a large cardiac population, I have seen some children who have broken my heart and challenged my conscience. Any of you who have dealt with kids with congenital heart defects know what I am talking about- ridiculous surgeries (time and time again), prolonged, painful intubations, chest tubes, line placements, sedation nightmares- most with the same outcome- a very prolonged death or a substantially limited life. I would witness rounds on these kids, physicians, residents, surgeons, fellows, and the occasional nurse- talking about the "plan for the day." Only when child is actively trying to die do we have those crucial conversations with families- when they are emotionally devastated- about outcomes and eventualities. Is this fair? Is this the right thing to do? Just because we say we can do one more surgery, should we? Are we perpetuating pain and suffering in the same of science and medicine? As nurses, if we do not raise these questions are we just as culpable? What do you think?

You are obviously thinking seriously about this transition and I congratulate you on that. Best wishes as you enter the PICU world. I will give you a few of my personal thoughts on your questions: 1. In a general PICU, respiratory issues are some of the most common reasons for admission to the PICU, especially during RSV season. However, if you are a Level 3/4 Trauma center, you will see lots of accidents (MVA's, falls, head injuries and non-accidental trauma). Additionally, if you within a major pediatric center, you will also get sick heme/onc kids (either newly dx or septic); a large percent of the population are your chronic, technology-dependent kids who have flares of their underlying illnesses (seizures, pneumonias, etc.) 2. The kids who graduate are the ones who are usually admitted acutely ill and get better quickly. Sometimes, you just return kids to baseline. 3. There are no "born" PICU nurses- you just evolve. Naturally nurturing individuals usually have to develop good coping mechanisms to survive, otherwise they burn out emotionally. If you are a flexible, yet competent clincian (this takes study and time) who loves kids, you can succeed as a PICU nurse. 4. Safety becomes part of your personal culture- especially when it comes to high-alert drugs, clincial distinctions within PICU, and just plain common sense. It is learned with time and experience. You will get there- be patient! Passion is everything. You seem to have it in spades!

No, they hire new grads. But one question, why Duke? There are other great hospitals in the area. Check them all out before you make up your mind.

We live on the Durham/Orange County boarder- but technically in Durham Co. The schools are a problem, I am sad to say. However, Chapel Hill is much more expensive, so you will get less house or apartment for the money. There are some great neighborhoods in Durham, near the Cary/Apex line. Overall, it's not a bad place to be, but I would tend to steer clear from downtown Durham- it is getting better, but not there yet.

Congrats on your new profession! I am sorry to report the salary ranges for new grads are not comparable to those in NJ. When I moved from another state in the southeast to NC with over a decade of nursing experience, I was offered a base rate of less than $26/hr- an almost 20% cut in my hourly rate at my previous job. You will find some of the RTP area hospitals are better than others when it comes to salary- some are counting on you to focus on name and prestige, rather than the bottom line. Take my advice- shadow in each area, do your homework, and go with the unit and the hospital that fits your personality, versus reputation. Good luck and best wishes.

After many years working as a bedside nurse, I entertained the idea of going back to school for my peds critical care PNP. I have worked in units where they are utilized aggressively in patient care, with responsibilities equal to a Fellow. However, what I have come to realize is I love taking care of patients. I love the close interaction and bond with kids and families- something that can not be achieved as a PNP or MD. The reality is that many nurses are searching desperately for respect and value- and the way many of them think they are achieving it is by leaving the bedside for graduate school. While I have great admiration for those who are looking for more education, I encourage my fellow peds critical care nurses to embrace the invaluable place they take in health care. You are important- no matter how many letters follow the abbreviation RN.

Hi there! I my experience, we use both sedation/pain scores (RASS,FLACC,FACES) to assess the adequacy of our sedation/pain management. We also require any means of restraint (soft wrist, Welcome sleeves) to be discussed and reordered every 24 hours. We also document the location, perfusion, skin integrity of the extremities restrained q2hrs. Personally, if I have reliable parents, I will let them hold little hands and give them a break if I can. Drugs are great, but let's face it- these kids who are intubated for weeks at a time go through them like elephants. Pretty soon, we have kids on versed, fentanyl, dex, ketamine gtts along with hourly boluses of pentobard and the occasional ativan. So, what are we to do to keep our patients safe? Restraints are an ineviatable intervention, necessary, yet difficult. One last thing, remember kids are easily distractable- so if the tolerate any kind of stimulation, soft music or familiar movies/TV shows. Good luck!

In 15 years of nursing (all areas from ED to critical care) I have never eaten in a break room. I don't have a problem with those that do (you all probably have a much healthier digestive tract), but I always feel I am putting an extra burden with my pod mates, especially if I have a busy assignment or vice versa. Take your break, but don't make a fuss if you don't get it when everyone else around you does not either. Keeps good Karma.

1 Before you even touch the kids, make sure you have EVERYTHING you need in mulitples in an organized fashion on a table, blue pad, easily visable. Open you alcohol wipes - lots, flush all your lines AND MOST IMPORTANT, HAVE YOUR SECUREMENT DEVICE READY- either thin strips of tape for chevrons or stat locks (which I highly recommend) 2 On kids with lots of subq tissue, lights will not be that helpful, unless you are looking a thumbs or fingers (good sites for pudgy kids with no veins) 3. Remember to start distally so you can work up as needed. If a child is going to need long term access, you might want to avoid the AC's in the arms so the PICC team can use them for lines 4 If you have a baby, papoosing in probably the most secure, less traumatic means of restraint- and remember your sucrose on a passy for soothing- it works! 5. FYI- my favorite sites for difficult sticks: saphenous veins on the interior aspect of the ankle- they are always there, just have to find them; also along the outside of the foot on the bottom, veins run horizontally along the side and are great sticks. For infants, no question- scalps rule! My personal preference, no rubber bands- just have your helper place a finger firmly, but not completely occluding the vein outflow. This prevents these large, but somewhat fragile veins from blowing. And, not to be stupid, make sure you point the catheter toward the heart. I know, it seems stupid, but I've seen it happen the other way around:nurse:. Good luck and keep sticking!

As long as she acquired the immunizations legally according to the laws of her state, she is perfectly within her practicing rights as an RN to administer them. She should have notified dad of the injections for appropriate monitoring and interventions as necessary. As to the legal ramifications, as long as the agreement between herself and dad was not infringed upon in making medical decisions unilaterally, no infraction occurred. Good for her in keeping the kids healthy. Maybe the lines of communication between the adults should be a little more open.

It sounds like an appropriate dosage of Tylenol, but written in a dangerous way that could be misunderstood. She should have either a scheduled dosage or prn, but not both. Ativan is purely for anxiety. You are right to consider her liver function status when administering meds. Are her LFT's elevated?

You will probably have to go to the RTP area and look at Duke or UNC. Both are good programs. Do you want to work in a hospital or outpatient?

Update on my post: As I am sitting here typing my update, I have come to realize my new career is as a Barista at Starbucks! What a happy job that would be! Nothing new to report, just more of the same, more isolation. I have emotinally left this place, showing up in body and mind only. I'm sure it shows, I no longer care about anything more than making sure my patients are safe, cared for and getting through my 12 hours. Thanks for all the kind words. I really appreciate this forum, but also find it so sad how many of us have toxic work environments. Tragic.

I believe you are correct. In order to drain the EVD, the stopcock would have to be off to the transducer, in which case your numbers on your monitor would not reflect your true ICP. Did your nurse following you go postal because the montitor alarm was turned off? Is this against your policy and procedure for montioring ICP via EVD's? Was your charting in step with your documentation policy and procedures? Review those things for future reference to know what the expectations of your new unit are. Things are done differently everywhere. Your understanding of the procedure of monitoring and draining EVD's was correct in my book. BTW- was there an order to open the drain if ICP > 15 or 20 for more than 5 minutes or was it draining continuously. If your bag was 20 cm above the EAM- probably not putting a ton out anyhow. Good Luck

Hi everyone: Sorry it has taken me so long to get back- I have been too busy having a nervous breakdown. I love your comments and encouragement. It is so amazing how much support you can get from a bunch of strangers- only you are not strangers, you are nurses! I wish I had better news to report. I have gone another 2 night shifts with a sum total of 3 people interacting with me (including the charge nurse who came to get report). I have come to the point of no return. I don't think there is one thing that could be done to make me stay there- not more money, not day shift, not a cruise to the Caribbean. Jan, you mentioned a scale measuring relocating stress- I am off the chart. Not to be gross, but my periods won't stop. My memory and level of distraction is unprecedented. I am crying- all the time. THIS IS NOT ME! I don't do these things. I am almost afraid I am coming apart at the seams. About to call my mgr for a meeting- just can't quite press the send button yet. I feel like my career will end if I do. However, the thought of entering that unit one more time- I just can't do it..... Thanks for listening. This too shall pass.