shocker29

I read it when I first became a flight nurse. It was really good, but really focuses on the urbanized area... I work in a more rural area, so the way our flights work is a little different. :)

I work at St. Luke's in the CCU and love it. A year ago new grads couldn't find jobs to their lives, and now it seems that everyone is hiring again.

A really good ICU orientation will have adequate education, ie: a critical care course that they put you through and several months of orientation. I went to my unit as a new grad and we got a 3 month critical care course, a 5-6 total orientation period (longer for some if they needed it) 12-lead EKG courses, ACLS, and multiple educational opportunities. Even experienced floor nurses get the critical care class and a 4-5 month orientation. What I think is REALLY important is the unit director... what is the attitude? Will they take time to work with you if you need it? Or will they let you go if they feel like you aren't ready after an X amount of time?

Her calcium was probably lower because she had gotten 5L of fluid in. Personally, if the first liter or 2 doesn't work (unless the patient is CLEARLY dehydrated) I would have recommended doing something else. 5 liters is alot to bolus a patient who is not in critical care. It is likely that she does need her albumin replaced, and is a lot less risky than pumping someone with that much fluid. They could have also tried switching to a hypertonic fluid, but you have to be careful that you aren't messing up the electrolytes even more. If the patient's creatinine and BUN are fine and you have tried a bolus, I know that a lot of our intensivists would let it hang. Would probably also have given more lasix (as long as the BUN/CR stayed fine) to get some of that extra fluid off. This is kind of touchy, but I find that some of the non-critical care docs don't necessarily have the expertise needed to really effectively manage problems that are outside of their specialty range. Chances are, if the patient was in a critical care unit, the low UO would have been handled a bit different. You said that the patient ended up being discharged to a rehab, so it doesn't sound like harm was done (hopefully), but the probably might have been handled in a fashion that was better for and more comfortable for the patient.

Hypothermias are fun, if done on the right patient. These patients are a 1:1 in our unit until they are warm again. (Supposed to be a 2:1 while inducing, but that never happens anymore.) We have a central line that can be placed that is actually a cooling catheter. If we can get the doc to insert the line, then this machine circulates ice water and cools the patient. In that case, we assist the doc with insertion and set up the machine. If we don't use the cooling cath, then we have to ice pack the person and ice lavage them down their NG/OG tube. It's way easier and less time intensive if you have the cooling cath. The patient is paralyzed, so we are doing peripheral nerve stimulation hourly to q2 hrs to make sure the patient is not over paralyzed. They are also obviously vented and sedated, so we monitor their BIZ to make sure they are not waking up. We keep them at the target temp for 24 hours (32-34C) and then stop cooling and let them passively rewarm. The big thing to watch for is dysrhythmias, especially when they are cold. If you are icepacking manually, it is really important that you watch for "drifting".... the patients temp can dump very quickly and every point under 32C, you majorly increase your dysrhythmia risk. When you start re-warming the patient, they dilate out and get can hypotensive quick, so usually pressors are part of the order set. It all kind of depends whats going on. We have seen some truly amazing success stories. However, patients are often induced now that don't meet the criteria and we are doing this on some patients that never had a chance. Hypothermia is supposed to be indicated after a witnessed v-fib/V-tach arrest, in which CPR was started within 5 minutes. I understand going outside of this criteria for lots of things, but we are getting patients who were down for an indeterminate amount of time, and were pretty much DOA with a heartbeat and 3 days later they are the same. That's a physician issue... it goes between docs wanting to give everyone a chance and docs afraid of getting sued.... I don't know. Anyways, amazing recoveries lots of times. :) Hope this helps. I like hypothermias :)

GaMBA, If a nurse is working a 12-hour shift in a hospital and hardly catches a glimpse of her patient, then it sounds to me like a nurse problem... I hope you get that I am not slamming doctors in any way! Nurses really do spend a lot more time with patients in the hospital than doctors. (I am saying patient A may see physician for 10minutes, but sees you on and off for the entire shift.) That is simply the nature of the profession. Doctors see so many patients in one day that it is impossible for them to spend more time with each patient. We'll have to respectfully agree to disagree

GaMBA... you gotta think hospital nursing! (which is where the majority of nurses are based...) The doctor takes about 10 minutes to an hour to admit the person on their first day, depending on how stable they are, and then, omitting crises, about 10-15 minutes per day with each patient. Nurses are there and responsible for those patients 24 hours per day. It isn't a slam on docs, its just the nature of the job!

Doctors spend a very small amount of time with each patient every day. They come, write orders and go. The way I look at it, we are the ones making sure that all day/night long they stay alive to make it to another day. We are their guardians... on the front lines, in the thick of it... and that, I think, is pretty cool.

Sounds like this guy needs to be in CCU on a dobutamine drip...maybe even could have used a balloon pump to get him over the hump. I've never seen a patient with an EF of 10-15 that was not tachycardic! How tachy is the key! Lasix is really important for the heart failure perspective... these guys walk a fine line, so I understand why the lasix was ordered, but like everyone else said... you got to have the big picture! A cardiologist should have really been running this guys care...

You sound like you are really having a hard time. Take a step back and breathe! You must have stuck through nursing school for some reason! The first year is really tough, especially in critical care... you are learning how to be a nurse and how to be think in critical care all at the same time. Don't feel bad about venting that is why this place is here! Do you feel like you could talk to your director about how you are feeling? (I don't know that I would go in there and say exactly what you said here, but if she knows that you are having a hard time, she might be able to come up with some resources to help you... a good director will try and save the investment in the person and the unit. Maybe she can switch preceptors for you and give you someone who can serve as more of a mentor I bet it will feel good just to get these feelings off of your chest. Keeping it all in can make you so lonely and just feel so much worse. Hang in there, you haven't even been at it a full three months. This will most likely pass. Every nurse I know has felt how you are feeling at some point or another. That is a ton of money to play around with, not to mention the investment of putting yourself through school. I don't know you, but on a hunch, I really think you'll regret it in the long run. After a year you are free to do what ever kind of nursing you want... try a doctor's office or something! Nursing is so broad, no one has to be stuck in hospital if that isn't there gig!

Not at first.... I mean, give yourself a year first to learn about everything, and then go review the CD's... they will make much more sense then.

I think that I like the Allow Natural Death thing. Thanks guys. Alot of it is in the way you present. I think that is part of the problem, however as a nurse I always wonder when I am crossing the line when talking to the families about letting go. We have some physicians that are outstanding patient advocates when it comes to talking families in to letting patients go, and others that you just want to say, "what are you thinking?!?!" I think it really depends on how comfortable the doc feels in their own skin too. Some view it as admitting defeat.. they don't like saying, "sorry, you can't save em' all..." I think part of being able to recommend letting a patient go comes with time for them. Interestingly though, it seems like our biggest patient advocates when it comes to recommending DNR are some of our female intensivists.

Awsmom8, You must be an amazing woman :)

Wow guys, thanks for the quick reply! I was starting to feel like a bad person everytime I went to work! Sometimes it is hard to want to give it your all, when you feel like you are prolonging agony. (I always do, of course, I just feel like "this" the whole time!)

Shay, Your post was clearly a vent post. DO NOT feel bad for venting. Isn't that why we're here? You sound frustrated because you care! You just wanted this family to experience this death the way that they had said they wanted and you did your best to provide that for them. Sounds like between your expectations and their grieving/lack of understanding, that just didn't sink in this time. I think it is fairly reasonable to expect people to have been SOMEWHAT prepared (not yelling... just using caps for emphasis!), because that is the "responsible" thing to do. However, that being said, there are ALWAYS going to be some people that are going to let you down... that is one sure thing in life. Next time it doesn't seem like someone is "getting" it, just remind your self that this is one of THOSE situations and have a sit-down with that family and give them some gentle, extra-education... sometimes you just have to be gentle, but FRANK. And there is nothing wrong with that. You can only do what you can do.... I was running a code up on the oncology floor one time (actually first-code that I really ran as a CCU nurse off of my unit). It was a lady who had cancer, but was not at the "end." She was in Vtach, so we were doing CPR and getting ready to shock and I look over and her husband is taking pictures in the corner with his camera. I am thinking, well... I don't thinking that my mind could muster a thought. I was amused, appalled, confused... whatever. However, he was polite and calm and quiet, so I didn't care what he did. Got her back and sent her to the unit. I decided that maybe he should have been upset or something... I mean he watched his wife "die" and be brutally resuscitated! Where was the emotion??? He definitely must have some "disturbed grieving processes" going on. (Is that a real nrsg dx?) After talking to him, I decided that he'd actually just been prepared for something like this...She'd been sick for awhile... I think he'd been kind of documenting her illness, albeit, a rather morbid scrapbook, I'm guessing. When I reported off on this lady, I told the other nurses that the husband was just a little bit "eccentric." People will just be people, what are ya gonna do? :) Take care, Shay