Lisbeth

I transferred from med surg after several years of experience, hoping to be able to use my skills and be able to really focus on my patients. My orientation in ICU was 3 months, but was so intense that I was exhausted every day. I am still stressed that I am not remembering things or picking things up quickly. Everyone else around me seems to be very calm and efficient. I'm wondering now if I'm really cut out for this kind of nursing. Everyone in ICU says the first year is the hardest, then it will feel more comfortable; I've been there 8 months, and I'm anxious about going to work every day!

Our non rebreather masks have a rubber valve that looks like a washer that closes when the pts breathe in so they don't get outside air, just the oxygen. Then, when they exhale, the valve opens to let the exhaled air out so they don't rebreathe it. Sometimes our RT will remove the rubber valve, and calls it a partial nonbreather mask. I'm not sure why some pt's can get room air with the oxygen, maybe a venturi mask isn't available.

I've given heparin SQ in the anterior thigh also, when there were large abdominal dressings from surgery and I couldn't use the abdomen. I thought it could be injected in any subcutaneous fatty area.

I'm on the med-surg end of the transfers, and I the date of the last BM is missed a lot in our reports. It takes a lot of time to research the chart once the patient gets to our floor, and the ICU charting is different than ours. Also, the med sheets are different, since our ICU is computerized, and it is really difficult to figure out when meds were last given. If a patient has Q 8 hrs antibiotics, it would be helpful if the ICU nurse tells me the schedule. Another big thing I like to know is whythe patient ended up in ICU in the first place; for example, if the pt went to ICU after surgery, was it because of excessive blood loss or history of heart problems, etc. RN-PA is right about giving more rather than less information. I believe it probably goes the reverse way too...what information do you like to get from the med-surg nurses when they give you a patient? Thinking about what information is important for you will help you figure out what to say in report.

Is internship like orientation? Who is precepting or mentoring you while you are still new? This person should be helping you to adjust to the reality of your floor. Many new nurses feel intimidated by doctors who yell, the key is to not take it personally. However, sometimes we feel bad because maybe we could have done something better. It always helps to be prepared before calling the doctor; review the chart and med sheets, jot down notes before you call, and be very clear on what you are calling for. This way you won't feel so flustered. Practice saying the med name before you call. This is very important because there are so many sound-alike drugs. Just like anything else, the more you do it, the better you'll get, so try not to avoid calling doctors. There are going to be some rough days, and as you get more experience, the good days will outnumber the bad. As far as being a secretary: all of the tasks involved in patient care become the responsibility of the nurse, sometimes there are other staff we can delegate to, but ultimately we make sure it gets done, and it's all important for the care of the patient. Good luck, hang in there. When we have bad days on our floor, we just say, "It can only get better!":)

Thanks for the great responses. We don't use "teams", I'm not even sure how they work. We try to take acuity into account, and we can do that at the start of the shift based on patients already on the floor. Unfortunately, we get so many admissions on our shift, each nurse can get up to 2-3 admissions each day. Some are post-op, some are from the ER, and some are admitted from the clinic, home, or other hospitals. We don't know how challenging these patients are until we admit them, and then it's difficult to change assignments. I would like to think that it balances out over time, so that one nurse isn't constantly getting heavy assignments.

I work as a charge nurse on a med-surg floor and we are currently having discussions regarding patient assignments. We usually have the charge nurse on the previous shift make our assignments so we can all start work when our shift begins. Our floor is divided into four corners and usually the assignment consists of each nurse having a corner. If there are too many empty beds or admissions/postops in one corner, it will be split up. As charge nurse, I also have patients with an LVN, but I try to resource the other nurses and encourage team work. The dilemma is: do we assign the corner and have the nurse take the admissions that come with it, no matter what time they come, and the rest of the staff help out as needed; or do we assign only the patients currently in the beds, then assign admissions as they come in? Does anybody have any suggestions or experience with this? We have been doing it the corner way for years, and some new nurses are wanting changes, so I thought I'd look into it.

When I was a new grad in med-surg, I our hospital had a ten week orientation program. Currently, the program is six to ten weeks, depending on your experience (some RNs were LVNs first). The program is run by the education department of the hospital, and the new grads are buddied with an RN who has gone through a training program. You progress from observing, doing a floor scavenger hunt, hospital tour, etc to gradually taking on all of the patients that are assigned to your nurse buddy. Eventually, you take on more responsibility, with your nurse buddy always there as a resource and guide. The new grad is not considered as part of the staffing ratio. On our floor, we have 5 or 6 patients, so the new grad is expected to start with one patient and gradually add at least one patient per week, so there is an opportunity to practice time management, skills, etc with a realistic assignment. Good Luck to you, it is so exciting to be starting out. You picked a great career!

At our hospital, all post-op patients are offered pain medication every 4 hours for the first 24 hours after surgery. Fusion patients are turned/"logrolled" every 2 hours. We have "pathways" where the Dr orders are preprinted on the order sheet, and the Dr just checks off what he wants. There is an option on the order form to "D/C PCA on POD-1". It looks like the pm nurse you had just followed orders and didn't use nursing judgment. On our floor, we usually D/C the PCA after a couple doses of the po meds, to make sure the pt tolerates the po well. If the pain is tolerated with the pills, the patient usually ends up not using the PCA anyway. It is up to the nurse to make sure the medication is the right route for the patient. I am glad that at least you had good nurses aides, they don't get the recognition they deserve sometimes. There are times when their interactions with patients can prevent really a cranky patient.

I have been a med-surg nurse for 6 years, and started here because the nursing schools were still advising new grads to go into med-surg for their first one to two years. I always figured I could change/cross-train somewhere else when I got tired of med-surg. I still don't see that coming, I love my job, and I love the diversity. Some people (from other areas of nursing) say med-surg nurses are "jack of all trades, master of none" because they see a lot of different things, but not necessarily for long periods of time. But I have seen nurses from other areas float to my floor and practically drown because they don't have their time management down, or know where their resources are. I like that I still see and learn new things. Like Tweety said, it's a daily challenge; that's what keeps it from being boring. In my hospital, I only know one person who has certification, it's not really spoken of or recognized much. I did look into it one time, because I sometimes think med-surg is overlooked as a specialty area, but the test was in a city a few hours away, and I couldn't make it.

I agree that you handled it correctly. I would have talked to the nurse who gave me an incorrect report, and then I would have written it up (especially if she didn't have a good explanation or if she didn't seem conscientious about it). If it is a problem with the system it needs to be looked at so it can be prevented. If the problem was the PACU nurse, it also needs to be looked at because we have to rely on each other at work. We have to trust other nurses, even though we eventually verify the information by checking the chart. This situation also brings up a good reason to not say anything to the patient or family about diagnosis or prognosis until the doctor has discussed it with them.

I am curious if anyone is having problems at work related to the new ratios. Is it happening, and if so, is patient care better, or are hospitals cutting staff elsewhere?

We used to give our patients a pink enema that was called "Pink Lady Enema" and that's how the MD's would order it. The pharmacy would make it up with a mixture of things, like mineral oil, but I don't know what made it pink!

I once had orders on an eye surgery pt for 3 different eye gtts, five minutes apart, q 30 minutes.