nrsgnerd

(1) how important is writing in this profession? it is very important to write well and to be able to express precisely things such as, events, times dates, what was said and to be able to do so objectively. (2) how often do you write a day, a week? every day i work, i write and make nursing notes to describe a pts behavior, thought processes and what has been taught to the pt regarding care, medications and what to expect during the shift. (3) for what occasions do you write?see #2 (4) who do you write to? pharmacy for orders, nursing care orders, radiology testing, cardiology testing and also emails to managers-unit and/or case managers with questions or concerns related to my job or a service needed for the pt such as medication assistance or complaints from pts or family members. i also had to write out a detailed description of an event that was put in my employee file after a pt's family complained about me and threatened to bring a lawsuit against the hospital. the family member appeared to be under the influence but still and yet, this remains in my employee file and i have a copy of it for my own records. always make a copy for your own records!!!!!!!!!!! (5) do you write and/or give presentations? depending on what tier of nurse you are....the higher the tier the more responsibilities you may have. for instance, we have a heart walk with the american heart association each year so flyers and information have to be presented to recruit employees to participate. and if you get any type of financial assistance from the hospital to attend seminars, you are usually required to make a poster board or do a quick presentation about what you learned to your colleagues. (6) how important is it that the writing be clear and correct for this profession? extremely important. first off, nurses following your care need to know what happenned during your shift such as: times, meds given, problems, vital signs, changes. also, if ever you are called to court because of a law suit, you must be able to look at your past documentation and know that you met the standards of practice for your facility and to see exactly what care you provided so it can be deemed you did what any prudent nurse would have done. do you have it documented that you turned your pt. every two hours? if not and they got a bed sore....medicare could deny payment and deem the cost of treating the sore a "preventable medical problem" that was caused by negligent nursing care. did you document your ventillated pt's head of the bed was consistenly 30 degrees or higher? if not, and your pt. developed vap (ventillator associated pneumonia) two things could happen: one, insurance may not pay and deem it preventable or two a family member could contact a lawyer. i would recommend to any nurse to make at least one nursing note per shift, especially if a pt does not do well, has behaviour problems or if there are any type of family complaints or you see poor coping skills from family or the pt themselves. and especially if a family member request to see the chart or if they are writing down what meds are being given. (7) does clear organization in writing matter in this profession? yes, events need to be documented as they occurred with responses to those events as they occurred. you must use objectivity, and documented what you can measure...not what your opinion is. (8) are high school and college english courses essential for this career? why do you or don't you think so? proper use of grammar and the ability to spell and interpret what you read are very important. do i think you need to be a journalist...no. but when others read what you write, they need to be able to visualize what you are saying and you need to be able to comprehend at a college level the written word. (9) do you do research? yes, nursing is ever changing. new technologies, new cures, new medications are a constant as is change. there are so many diseases and some you only see a few times and you have to know what it is you are treating. its just as important to know what not to do as it is what to do. we recently had a pt who had brugata syndrome which i had never heard of. that night, i looked up an article at a creditable website, printed off the material and passed it on to the nurse following me who could not remember what it was either. we do the same thing with new medications, new machines we use, new policies. (10) do you have to write performance reviews? peer reviews, yes. and its not easy to always answer those questions. for as much as they want to know the positive attributes of a fellow colleague, they also want you to list where improvement may be needed. our charge nurses do write the performance review, each being assigned a certain number to do and a deadline to have them done by. (11) if so, is it important these are written well? why?of course, not only does it ensure that facility policy and procedure are being maintained but that nurses strengths and weaknesses are being described correctly. for instance, if i have excellent customer service skills but i am not engaged in doing anything extra for the unit then i should not be described as average for customer service and average for being engaged. also, examples of what i do or don't do should be mentioned in a way that my manager can visualize what is being said to prevent him/her from speculating or assuming. on a personal note, yes care plans are mostly pre-printed and its a pain to have to do them for clinicals...however, they do teach you what needs to be physically done for a pt and requires you to think through writing a care plan. yes, papers on disease processes are a pain, but it teaches you how to sort out creditable from non-creditable sources that you will seek out as mentioned above. yes, if you have to write out drug cards....its busy work, but when you do go to look up a drug, you understand the format of a drug reference and you know common from non-common side effects as well as important factors to consider like with lopressor (metoprolol) a beta blocker....always check a bp first and if the heart rate is less than 60 or if they are on any type of vasopressor...you do not give it....these are the little pearls you learn from the many writing assignments in nursing school that only serve to make you keen at documentation once your out on your own and its all up to you. hope this helps and makes all the busy work seem not so pointless for you.

we do our own and use the gambro prismaflex. our pts are 1:1. the documentation and keeping all the bags going is labor intensive as well as if you have a pt that you have to adjust how much your pushing and pulling off based on their tolerance. you definitely will have a busy shift. we go thru phases with how many we have on crrt at any one time. our unit is a 17 bed unit, so if we have 2-3 on crrt at the same time, staffing gets harder. we still use dialysis nurses for regular hemodialysis, they just bring the machine with them but we have our own prismaflex machines that we share between cvicu/ccu/icu. i would say we have pts on crrt monthly but it may end up being that we only had one pt that whole month just in our unit...not including icu. the pro is that it is a 1:1 (and will hopefully always be), you have to make sure you document well to keep the acuity high and justify the 1:1 nursing care needed. you pretty much camp out in the room with the pt or very near by to ensure you catch it if they start to not tolerate. you have to make sure the catheter does not clot off. you also have to think ahead of what you need, make sure you have it and keep good contact with pharmacy to get the fluids you need when you need them-we have most of ours in a designated cart outside the room but have to order calcium gluconate...etc.... its organization, keen watch over the pt., good documentation, think ahead, protect the cath site and make sure you get all the other pt care and meds given. bottom line....you earn every penny you make that shift!!!!!!!!!!!!!

Strong standpoint! Good for you!! I HATE INSURANCE COMPANIES! I paid for years for dental insurance and then when my daughter needs her wisdom teeth out, they file it under medical and tell me I'll need $1200 to have it done! What the hell am I paying for dental then??????????????

Luckily, our unit is 1:1 for IABP's and thus far no ruptured balloons. I am taking the class in the next month or so to start taking IABP's so it was good to read these posts.

Woah woah woah! Im on your side here. Lets remember there is more than one way to skin a cat. For instance, we just draw blood from the art line and do our own accucheks....we don't wait on lab results that can take forever in our hospital and its not common practice for us to do stat glucose unless the accuchek reads "high or low" Next, if you don't ask people for help then you can't say that they wont help you. Maybe nurses are on their own (as it sounds from your post) just because no one has taken the iniative to point out that teamwork makes for a better work environment. Since you are a new nurse, be a brave new nurse, don't be afraid to go against the grain. Its how you handle yourself now that will cause the nurses to either respect you or "eat you". But fear, thats only reinforcing them and giving them power to eat their young. As long as you are respectful and reasonable with asking for help then there is no reason for the work environment to be hostile. and if someone is hostile with you, let them know about it in a firm and reasonable way. However, if this environment is making you nuts then perhaps you should do your time to get your experience in and find an easier enviroment to work in. If it were me, I'd try to cling to other nurses that did show teamwork and talk to them about maybe starting a committee that promotes teamwork. Talk to your manager about bringing it up at the next employee meeting and see who wants on board. Make a bulletin with little rules of courtesy such as: No one sits down until everyone can sit down and things like that. You can google to find some good sayings. Adn to those that are resistant or don't seem enthused aobut it, kill em with kindness...go out of your way to show them that teamwork makes the environment better. Just make sure that your manager is enthusiastic about this because if she/he isn't then the older nurses may buck you all the way....I wouldn't waste my time unless i knew the manager would help me to reinforce this because she/he believes in it to be important. I once pulled a nurse into an empty room because she was rude and embarrassed me in front of patient. I told her, "Look, I will give everyone here my respect all day long but if you disrespect me then I will stand up for myself. I don't allow anyone in my life, personal or otherwise to speak to me like i am less than who i am so I am giving you the chance to not treat me that way again but if you do then I will get management involved." She immediately appologized and said she was having a bad day and didn't mean to come across that way. We have never had another problem and I learned alot from her. So see, there is a way to get your point across without creating havoc. Just hang in there and do what you can to make it a better place to work, for you and most especially for patient care.

Bob has the right to inquire as to why he is getting this new pt. when it seems clear that there are other nurses who are available/underassigned and more capable of being able to accept this pt. My question is what are the accuities of the other two nurses pts. Are they one on one pts? Are the other two nurses trained to take this level of OR pt.? Did Bob state any objection, now or previously, or is Bob such a nice guy he doesn't stand up for himself? I would have delegated a few things such as: asked for someone else to transfer my pt. ( pack him up, take him out, get meds ready...whatever) and ask someone else to get my meds or do accucheks for my remaining pt or whatever else i could have delegated to ensure that i stood up for myself and let Tameka know that she can't bowl me over. In the future, Bob should professionally state his opinion and delegate his needs thru his charge nurse.

You are in the same boat as me! I have just graduated and work in CCU/CVICU and as soon as one of my pts start having less than a perfect reaction to care I start to freak....though Im told it doesn't show, my Lord I feel it! I start thinking its me, i didn't do something they needed...what did I forget....am I safe to care for this level of illness...I need to google that...but so far, thank you Lord all my pts have made it thru my shift. I havent' had a code yet but don't take ACLS until FEB. Luckily our unit is a total team nursing unit and we all gravitate towards whoever has the sh*t assignment or the very sick pt and we stick together. Thats the only reason Im making it is because I work with such a great group of nurses and those who aren't on the same page as our main personalities never last in the unit. Just keep trucking as I think you have to do this for years before things just come very natural. And I know what you mean about the cool cucumbers that make it look easy but most of them have been doing this for a while so cut yourself some slack and I will try to take my own advice but you are sooo not alone in how you are feeling. Just give it some time and if nothing else, one day at a time!!

Boy, I understand your concern. Our unit has glass doors and the nrsg station is in the middle with desks inbetween each room. Our of 17 beds there are only two rooms that are not very visible and so we try to keep confused or unstable pts away from those rooms. I think you need to make sure you are documenting extremely well and bring this concern to the attention of someone other than your manager as his comment, "My manager says that in most hospitals you can not see your ICU pts" is false. You may want to bring up the fact that the hospital may have a lawsuit on their hands if a pt. falls/dies because they were not being appropriately monitored. If all else fails, I would find another job....your license could be at stake because they are not providing conditions that you can do what any prudent nurse would do to ensure safety....and lets face it....in any lawsuit safety of the pt. will always be the number one goal they are trying to disprove in order to win the suit. My best to you!

Utter persistence and try to get to know some of the people that work in the ICU if possible. Alot of times in nursing, networking can get you further than experience can. Start asking people you work with if they know anyone that works ICU, or call the HR dept of the institution you are applying and talk to someone there and explain your position. Keep an eye for job postings on the institutions website. My best to you.

I work as an RN in CCU/CVICU. I had a pt last night that has had a permanent stoma for years. The stoma is open with no type of appliance to hold it open. You can look straight down into it with a flashlight. At the top of the stoma, still inside the stoma, there is a small puncture hole that goes into the esophagus and the pt. had a Blom Singer voice prosthesis which is thIS little white plastic appliance that has a plastic tag that sticks out AND sits in the stoma. the very small maybe 1cm round piece fits into the hole and so he can speaK. He just occludes his stoma to do so. Okay, so heres the problem. 1. None of us have worked with this type of stoma before, or seen this little appliance or even understand the anatomy regarding how it was installed so its hard to picture exactly what was done, we can only go on what we have been told (very little). 2. After the pt had open heart surgery, POD 1, the pt began to expel green bile from the small puncture hole 3. The pt and spouse stated that the pt. has always coughed things up into the mouth and spit them out....now, nothing makes it as far as the mouth and only expels from the hole. Does anyone have any experience with this? The pt is still in our unit, and if there is anything I can learn to troubleshoot this prob. I would like to. I researched the net and can't find anything about bile coming out of the puncture hole. Obviously, something has happened from the time of surgery to now....for all we know anesthesia tried somehtng...who knows? And his ENT here in GA. gave the okay to change out the appliance, allowing the pt. to do it themself. We had Resp and myself at bedside and when the pt took out the old voice prosthesis the pt began coughing and green bile, copius amounts, shot out of the small puncture and it took several minutes to get it back in. The pt. sat was already not great 90-93 (which doc gave the green light to) and then desat'd during this, we had to ambu bag the stoma....scared the hell out of me. I hope someone can shed some light fast....the worst danger in this is if it continues, bile will travel down his stoma into his lungs that already look like crap, sound like crap...its one of those shifts where you know your just not going to be able to let it go. Thanks all who read.

"someone's perception of someone else's actions can be far different from the reality of the situation. especially a cna who does not understand the responsibility of the nurse on any given day". i was a cna for 12 years before getting my nursing license and being a cna has nothing to do with recognizing when a person is cursing and being sexually explicit in front of patients. a human being has the sense to know that this is inappropriate, inexcusable and i don't care what kind of stressful day you are having. these patients are paying thousands of dollars and trusting you with their lives. if you can't connect with people...then you have no business whatsoever being a nurse in the first place. it is our job to connect with people, enlist their trust in us as professionals and give them care to the best of our ability. if the patients want a friend to tell them jokes, i guarantee you, they did not come to a healthcare facility to pay thousands in order to find it. i understand your frustration from your last job, but if you are saying that you would not "tattle" on someone who acts this way in front of patients then perhaps you need to read your states nursing act again because you are mandated by law to do so! there are some things that you can go to a person to out of respect when you see a problem, but if they are willing to act this way in front of a patient how perceptive do you think they would be to respect and listen to what a cna tells them. she did the right thing and how you don't see that is beyond my comprehension.

I did not work 5 years in school and train myself to be a nurse to have "weak links" jeopardize my ultimate goal which is excellent patient care. If your mind is on joking, and having fun at work then your not thinking about patient care enough. Your going to miss something vital and your putting the patient at risk. GOD obviously had a lessen in this for the person who got fired and he has a lesson for you too. Perhaps it is to think and respond to a situation and not react to one. Nurses are seen by many people as hand maids and not as educated individuals that self-sacrifice and continually commit to further their education to stay abreast of new treatments, medications, disease process findings and technological advances. I, for one did not go into this to have a great time at work, I went into this to do God's work and serve his people to the best of my ability. In doing so, any joke I make is made at an appropriate time to enlist trust from my patient, not elicit a party. I do so to help them see me as a regular person but I stay aware and prepared to switch into nurse mode with any finding. If this person was having too much fun at work then she was not working and putting the patient at risk. God has the ultimate say in all things so if he truly wanted her/him there then they would still be there. You just have to trust that he knows what he is doing and let it go, its gone and nothing can be done now....move on!!

First of all you can call the lab and ask them, or better yet the physician who should be well versed and able to help you. Do you have a heparin protocol? We do in our CCU, and we draw an AntiXa which is more specific to see if heparin therapy is at a therapeutic level and we draw this while the heparin is running and titrate the drip according to what the protocol calls for. If your not in a CCU but have a CCU/ICU/CVICU then call and ask the nurses there what they do. Regardless, if you turn the heparin off you may not get a true PTT because heparin clears the body pretty quickly. I know that when we are going to pull a sheath on a cath lab pt, we turn the heparin off for 90 minutes then draw an ACT (clotting time) and if its less than 180secs then its consider safe to pull the sheath out and hold pressure for 25 minutes. The bottom line is that you want to know that you are not overcoagulating the pt. so turning off the heparin before drawing will skew the PTT and put you at risk of over coagulating the pt. Hope this helps!!

I have met some wonderful LPN's, however, alot of hospitals are getting very technologically advanced these days and do want to hire RN's over LPN's. You can also call and talk to the nurse recruiter at a hospital you'd like to work at and ask them if they hire LPN's in the ER so you know where you stand. RN's make quite a bit more money and the schooling can be from 3-4 years depending on if you get your Associates Degree-RN (3yrs) or your Bachelors Degree-RN (4yrs). there are some programs that let you become an LPN and then you go to work while doing additional classes to get your Associates or Bachelors (some schools offer a majority of the classes online as well). LPN's are hired quite often in Nursing Homes or Home Health and they are needed. My suggestion to you would be to set your ultimate goal as becoming an RN after you get your LPN or looking into a program that you can go straight to becoming an RN. You'll be restricted on what you can do with an LPN is my point but it is a great place to start if you just want to get done as quickly as possible with school so you can go to work. As far as stress, school will be stressful and there is no sense in doing it so fast that you barely absorb the material. Nursing gives you the power to heal or kill a person so its very important that when you do begin your program that you give it your all and not overextend yourself to the point you make yourself sick and miserable. Not to mention alot of surviving nursing school is having good coping skills so if you go into it already freaked out, its gonna be twice as hard for you. So relax, take a deep breath and tackle things one at a time. Read a good book on optimism or positive coping skills and above all else, pray. My best to you!!

So, just to give a little background, I'm a very type B personality EXCEPT when it comes to work. There I thrive on being the best, very Type A and for the past 12 years I have worked as a CNA/TECH. I got the name Super Tech several years back from Peers and I am 100% about patient care. I graduated nursing school where I also excelled and so when it comes to nursing I hold high expectations for myself. OMGOODNESS, I am sooo a novice and had no idea what the world of being a nurse really was. I work in CCU/CVICU and I run like a chicken wiht my head cut off. I'm still developing a routine, and I forget things because of my lack of experience in the RN role. From a techs perspective it always looked like RN's had down time and for me, I've yet to have any. I don't even recognize my bladder calling me until my shift is over or if I'm at lunch....I don't drink anything practically all day and all I can think about is "What do I have to do now....what am I forgetting....oh crap I had meds due an hour ago.....theres the doctor, what was my K+ this morning...can I run this gtt with whatever other drip...did I remember to do this or that. Basically, my brain is in overdrive and I feel like I'm swimming against the tide all day long. And then today, I had my first interaction with a difficult situation in which I had a patient that came in 12 days ago after v-fib arrest and had emergent open heart surgery. The patient is ventillated, having myoclonic jerks, no purposeful movement but alas had brainstem function so his HR, BP are fairly stable. We had a doc tell the family to not let anyone tell them that their loved one was brain dead....and then another doc tell them the prognosis was poor. So ofcourse the family only wants to talk to the first Doc who was basically shooting psuedo-rainbows out of his butt. The pt has had two EEG's, with no changes and its undetermined how long the pt was down in vfib. Because the pt had a 100% blockage to the Left main, he was rushed emergently that first night to open heart surgery, no hypothermia treatment was given. So heres this pt, jerking....lungs coorifice/rhonchi and the children do not know who to believe about the prognosis. One grown child is having anxiety attacks and has visited our ER 3 times now for anxiety and the other is just annoyed and ******. There are 2 other children who we are told don't agree with how to proceed with care and the pt has a sister that the daughters want us to withhold information from. They want no one coming to visit except for them and it seems that in all their grief they are just not seeing the ramifications of letting this saga drag out. So far, no skin breakdown (but were getting close) but there is fever of an unknown origin, WBC's 12.1 which could just be neuro but we drew blood cultures today. Anemia ofcourse, so we infuse a unit of PRBC's and the anxious daughter makes another trip to the ER. We finally get rainbow doctor to come back and talk to the two sisters and he skirts telling them what we see as healthcare professionals (perhaps fear of a lawsuit...who knows) and it takes about 20 mins for him to finally say it...."poor prognosis....1% chance of a "meaningful" recovery. In the meantime, we are waiting on Insurance to clear him to go to a longterm vent facility (limited resources) and it seems that everyone except for the patient is being thought of. We have our intensivist doc, cardiothoracic surgeon, cardiologist, neurologists all either saying something different or just not rounding on the patient. We tried CPAP and the pt had long apneic periods. His muscles are atrophied, his EF before surgery was 10% and I feel like we are just sitting and waiting for his kidneys to shut down,nephrology to get involved and start dialysis. I suppose today was the beginning of me growing a new skin but I get so broken hearted for the pt because I know how this could progress. I love being a nurse, I guess I just have to get used to and learn how to deal with this situation. How do I let this not keep me awake at night? Do I just need time or will I become another jaded RN? I don't cry outwardly very often at all, but inside I weep for this pt.? Why is it that I have a hard time feeling for the family? I know its their parent, I know they just aren't ready to let go but it is so sad watching and just waiting. For all I know, the patient is in pain......or maybe he doesn't feel a thing. I hope its the latter. Any profound wisdom from experienced RN's in this field would be much appreciated. Thanks for reading my rant!