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.

What wonderful, encouraging words. I hope you never loose your passion. You are the kind of person that will give nursing an excellent reputation for being a caring profession. Keep the kids at your center and you will never stray from your purpose. Godspeed

Oh Jan- you are so wonderful and have an amazing capacity to do the right thing- I can hear the kindness flowing out of you. I am already out of orientation (4 weeks), so there has not been lots of time for details. But your example about using Interlinks are right on. We use manifolds for everything- we stock y-sites but no one uses them. I asked why and the response I got was- "this is they way we just do it." We use pressure caps on all our lines, a very antiquated item that was found to increase BSI. Could I bring this up? No!!! I have tried kindness, but it is met with blank stares of disdain. The night group is definitely more cliquish than days. Oddly enough, it is not the nurses who have been there for 30 years that are the problem. It is the ones who 5-7 years out that are the most difficult. I know I have withdrawn to some degree, because I am tired of trying. This isn't an excuse- I need to take the high-road. But I am drawing from an empty well and I don't have the emotional resources to make such efforts. I know I need to give it time, but the thought of entering those doors again makes me want to vomit and cry at the same time. Sorry for the pity party. Thanks for listening.

Okay: I need HELP! After over a decade in peds nursing, 7 in PICU, I have just changed hospitals due to a move. I have never encountered such a group of snobby, cold people in my entire life. This unit, I just found out, is notorious for not accepting new experienced nurses- which is the stupidist thing I have ever heard. They had rather have all totally new nurses than have to deal with experienced nurses who know how to take an axillary temp without having to be told the procedure. (This is not criticism for new nurses at all). I can't decide why they are so suspicious. I have never been so unhappy- ever. I can go for entire 12 hours without anyone even talking to me. I am usually the person people LIKE. Even worse, I am having to rotate day and night shift, which I haven't had to do for YEARS! It is the longest 12 hours of my life. The saddest thing is this is a PICU of really sick kids who need nurses who know what they are doing. I see a group of individuals who see procedures over patients, very little interaction on a human level. I was actually told on my first day that it was not acceptable to perform a certain procedure (best practice, PALS) because it was not "their way." Then I was accused of being "overbearing." I am in nurse hell and I don't know what to do. I have been told to "hang in there and prove myself in their way of doing care," something I find totally ridiculous, since I have had the sickest kids on orientation, already participated in 2 codes, had a kids on ECMO.. etc. How can this be right? How can this culture still be present in 2008, in a day we are so desperate for nurses? How can we expect anyone to stay in a profession that is so vicious, so backbiting. When will we change? My question is- should I tell them all to shove it and do something else? What will I do when my husband has a nervous breakdown when I tell him I quit? One caveat- I just finished my 2nd night shift and I feel so depressed I don't know what to do. Thanks for the listening ears. I know how wonderful this group is and I know you will give some good, clear, non-sleep deprived advice. :bluecry1::bluecry1:

What do you use to take report? Do you have a standard sheet? I have seen nurses make their own specialized form on Word, including a time slot for each hours vital signs, I/O, meds due, prn's given, reminders for that hour and any exceptions/interventions you complete for that hour. This might seems like reworking, but if you are unable to get to the chart or if you are unable to log into your computer, it might give you a way to get the information down before you forget it. Of course, if you are like me, you leave your peripheral brain (as I call it) all over your unit and spend an hour looking for it. I have yet to find a solution for this one!! Keep up the good work. You will find a system that works for you.

If you tilt the syringe at a 45 degree angle, the fat will also fall with the rest of the milk. Been there are done that.

Motor Mama: You know, I think it really depends on the situation. Trauma is much harder to deal with because of the suddeness and violence involved. Often there is not an opportunity for closure for families. Abuse is also terrible. There is nothing worse than seeing a child die alone, because their parent is in jail. I have seen my friends pick up a dying child and place them in their lap at the time life support is withdrawn or a code is called, just so they will not die in a strange bed, but in the arms of a loving person. Prolonged illness and suffering is different. Sometimes, death is such a blessing. There is time to say good bye. We each do what we have to in course of a day.

kessadawn: What a beautiful idea for the huggy bears- I am going to pass it on We also have a very specific process for bereavement, including a lovely memory box. We include hand prints, locks of hair, pictures ( we take them no matter what and then ask after the death multiple times if the family would like us to include them. Sometimes, they will say no, then change their minds later.) We also do hand and feet molds when possible. We have staff sign letters for year memorials. We also include anything in the memory box the family requests, blankets, clothing, etc. Once I had a father ask to take home the pulse ox cable, ECG leads and IV board. I didn't even blink, but included them in the box. Our problem comes on the weekends or holidays when our PICU chaplain and child life specialist are not there. We have chaplains on call, but they are usually students doing their hospitals rotations, having no idea how to cope with the death of children, the developmental considerations for siblings ,etc. The PICU nurses have had to learn how to deal with the details- calling funeral homes, organizing baptisms. This is hard, especially when we are dealing with the patient, the parents and the actual process of dying. A GREAT resource, one of my favorite dog-earred books I read from time to time, is Elizabeth Kubler-Ross "On Children and Death." Wonderful information, comforting and strangely uplifting. Purchase a copy, read it and pass it on to your colleagues. Godspeed, dear friend. There is no more important task than the one you are undertaking.

The AACN occasionally has PICU specific articles, but not many. Maybe this is a sign more of us PICU folks need to be more proliferative in our professional writing and research. I know there has to be a need for nursing specific information- just look at our forum!! I go on-line a bunch- http://www.sccm.org- society of critical care medicine has pediatric specific information. Like Jan says, it is medically focused, but is good information and up to date research. Let us know if you find anything more out there!

What makes PICU different from an adult ICU? I know this seems like a stupid question, but I think it helps focus the relevance of syringe pumps in a PICU setting. The concentration of continuous infusions can be so minute compared with adults (fentanyl gtts of 10mcg/cc or vec gtts of 1mg/cc or dopamine at 800 mcg/ml) and are weight based, that any drip less than 1cc/hr might not be accurately infused on a regular infusion pump. We use smart pumps with guardrails and they are programmable at increments of 0.5 cc. I often see many drips running at 0.15cc/hr at maximum concentrations Also think about the risk of over-infusions. The benefit of syringe pumps is usually the maximum volume that can be infused is in a 60cc syringe. Many antibiotics are such small volumes to be infused. How do you accomplish this, especially on meds like vancomycin that are infused over an hour, or meds like flagyl or abelcet? If you have limited resources, reserve your syringe pumps for meds that require continuous, small volume infusions at higher concentrations impacting sedation levels or hemodynamic status (PGE, inotropes, pressors, viagra). Hope this helps! I take for granted having all the syringe pumps I could possibly need at the drop of a hat. Thanks for keeping me grateful for the big things in life

Your hospital should have blood administration policies for each type of product. Some blood banks pre-filter platelets, some do not. The previous writer is correct- platelets, factor, cyro, FFP can be given faster typically than PRBC's. However, I have pushed packed cells in an emergency situation, but you need a physician's order. Remember, platelets typically can generate more antibody creation (and therefore reactions) than any other blood product. We can see platelet levels drift to less than 20K in some patient populations (heme/onc, HUS, auto-immune) before we transfuse. Classic s/s of transfusion reaction are hemolysis, hemeturia, tachycardia, tachypnea, fever, feeling of impending doom or severe anxiety. If you suspect a reaction, stop the infusion immediately, KVO with normal saline, call your MD and do not throw anything away- tubing, bag or paperwork. Hope this helps!