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

So, I was going to post this on the critical care sites, but I think its pretty relevant to nursing as a whole. I sincerely hope that no one gets the wrong impression here. I am a very empathetic and compassionate person. I love people and I love helping people - that's why I'm nurse! I also feel like I am a pretty moral person. I guess you could call it a little bit of depression that I have been dealing with lately when it comes to a specific group of patients, and I am falling out of mainstream here. I work in a busy CCU/MICU. Love my job as a whole. Went into critical care because I wanted to deal with the sickest of the sick. Found the prospect exciting. Came into nursing feeling like every life was important (and still do!) and quality was in the eye of the individual. Who am I to say what quality is for each individual? However lately I have found going to work depressing. Not because my patients are sick... I can handle that no problem. It is the people who have "poor" quality of life that we are endlessly keeping alive. This is the end-stage, chronic illness type, usually elderly person who would have probably have loved to "meet Jesus" before the family made the decision to have them intubated, or have other life pro-longing care. I hope this is coming out right.... It just makes me sad taking care of these miserable, elderly people with no quality of life who are being sustained on and on because the family will just not let go! Not because I don't want to take care of them, but because I care about them! I mean, how many of them, if they could see their future would say, sign me up for that! Families have such a hard time letting go sometimes. I guess sometimes it is guilt, sometimes it is desperation and a lot of times it is just lack of education and understanding. Like when when an 80 year old man is resuscitated post cardiac arrest and brought in to us. All of the hypothermia in the world is usually not going to bring 80-yearold grandpa back to where he was (and if he had delayed cpr) or even conscious. If he does go home, he is usually not the husband/father/grandfather he was before and everyone is upset. (Don't get me wrong, hypothermia IS amazing and works out beautifully in alot of cases). Do you get what I am saying? Sometimes I just feel like I am a villain, working in a torture chamber. Does anyone else feel this way? People just don't get what they are signing their family members up for sometimes. Then again, there are those cases, where everyone said it was pointless, and here the person is, walking out of the hospital as good as new....(exception, rather than the rule, for sure). Sorry for the super long vent. Tell me what you think. Thanks.

Okay, so this is something that I realized after the first year that I was a nurse, and I am going to go out on a limb and say that this is fairly universal: My entire first year was a complete love hate relationship and there was more than once I sat in my car, ready to drive home in tears. Everyonce in awhile, a co-worker was a little "snarky" with me, but really I work with an outstanding group of people. I think it had more to do with me feeling inadequate. We really have a great director, though I don't always agree with everything she does. Most if it was just the learning curve being hard, and me always worrying that I wasn't good enough, that I missed something, etc. Towards the end of the first year, it was (now, this was a critical care unit..), why aren't they giving me harder assignments? Do they think I'm not up to it? Finally, after the first year, I think that you begin to realize that you are going to be okay... that you made it. The more confidence and assertiveness that builds, the better you feel. I think pretty much every nurse goes through that the first year. You just feel like crap everyother shift and wonder if you made a mistake. But most of the time that will pass and you will be just fine. Attitude has ALOT to do with it. Positive people who are receptive to learning usually do just fine. I think that three 12-hour shifts is more like the rule and not the exception, atleast where I am. Some people add an 8 hour shift in every two weeks. I don't know of anywhere around here that does mandatory overtime. Infact, most overtime has to be approved by the super-higher ups and is frowned upon. Alot of people I know have second jobs for more money opportunites. Starting wage around here is $22/hour.

Okay, so this is my honest opinion... It seems to me that male nurses get more respect than female nurses do. If not introduced right away, the patients almost always assume that they are a doctor...(hmmm, I've never had that problem... I must not look official enough..) Even when they figure out the guy is a nurse, it is almost like, "okay, finally someone who knows what they are talking about!" Sheesh... not all patients are this way, but it is kind of like how my grandma always liked my brother better. THEN..... Okay, I swear this is true... there are some female doctors who have split personalities when it comes to the female and male nurses.... Male nurse? You've got Miss Congeniality. Female nurse? They might as well say, "I don't need your suggestions, every question you ask, I'm going to try and make you feel as stupid as possible and since, as another female, I feel like you are threatening my "authority" I am going to make sure you know who is boss!":eek: Okay, so most of our female doctors are NOT like this, but there are a few.... However, I know a male physician or two that will get a little foul-mouthed with the male nurses when they are angry... haven't had a male physician tell me where to go yet...

I know no one has posted on this one in awhile, but I have to say, who ever said that neuro ICU's aren't real ICU's are nuts! I work in a coronary care/medical intensive care unit. Our other unit is a surgical intensive care unit, but we get neuro patients (every once in awhile with ventrics) on our side. I love coronary care ... the patients heart stops, you code em! Septic? If it gets really bad, you code em'! Neuro.. the pt starts to herniate their brainstem.... sure you can code em, but it won't fix the problem... you're SOL! Worst night I have ever worked by far was the night that I had a patient with brain abcesses almost herniate their brainstem. That was tough stuff! Kudos to neuro ICU nurses! (They are trying to turn our hospital into a neuro center of excellence, so I guess our unit will have to get used to it...)

I doubt those meds were strictly home meds since that person had been in the ICU for awhile. Probably monkeyed around with quite a bit, if they even started out on them. Good chance that they didn't start out on dialysis.

I am an ICU nurse, but I won't rush to the title of expert... I understand your thinking. Usually though, in my experience, if someone's pressure is going to take a major dive, it is going to be during the dialysis run. That is usually when we have to kick on the pressers. 2-4 liters is alot of fluid (depending on the patient's unique situation), so that is definitely something to keep in the back of your mind. However, the patient made it through dialysis, and still had a systolic in the 120's. You would have to look at a number of different factors. How much fluid does the patient usually have dialyzed off? Is this pressure consistent with what they run after dialysis? Do they normally get all three meds after dialysis and do okay? I am assuming this info would be available, since this person sounds like a long-term patient. If I didn't have any of this info, I would have to look at the dosages of the meds. I'd ask the patient if they had been on these for awhile. If they had (and had also been on dialysis for awhile), then they will probably be okay. The hard position that you were in is that you were the student... it really wasn't your ultimate decision whether or not to give them. However, you were definitely right to ask the question. And anytime, if you don't feel comfortable, politely ask the nurse to give them. When you are an RN, you will have the lee-way to do more critical thinking and make the decisions yourself. You could certainly stagger them a little (as long as you have a good rationale to back yourself up) or even call the doc if you are really worried. However, with a systolic in the 120's, you have quite a bit of lee-way in either direction. Hope all that rambling helped...

I understand how you feel... I was in somewhat of a similar situation. I work on a busy critical care unit. Someone who had been hired right around the same time I was, was asked whether or not he'd like to take the charge class. I was talking to the person who did the schedules if she had heard anything about the management putting me in the charge class. this person said something like... "oh, no, you aren't ready for that." Naturally, I left thinking... well, what's wrong with me? It's not necessarily that I even wanted to charge... but I was wondering what it was about me that made them pass me up? Was there something that I was doing wrong? So I went into my managers office and just said, "I heard that there was a charge class coming up... so and so said I wasn't ready, and that is okay... but I was wondering if there was something that I needed to work on?" My manager looked at me blankly for a second, and then was like, "I don't know why and the world she would have said that, you are already on the list!" Now, if I hadn't already been on the "list," atleast I would have known what I needed to work on and it also made me appear like I was sincerely looking to better myself, which was the truth. If I were you, I would try this. Atleast then, you won't be at home agonizing over why they didn't pick you, and it will only score you points if you are polite and humble.

Wow, how do they get away with being late every day from management?? 2 minutes late, maybe... but even then, people get irritated. We are expected to be ready to go AT 7pm. Be 15 minutes late without calling once or twice and you'd be having a sit down. Personally, I have kids to get to school in the morning. If I am getting out late because my patient crashed and burned all night, that is one thing. But if the oncoming nurse is like, 10 minutes late, you better believe I'll be writing report. It is not my responsibility to stay... otherwise, I'll be giving report to the charge, and they will be giving report to the nurse. And just a note... if they expect you to get out by 7, then they need to provide a way for you to do that. They can't just refuse to pay you overtime, that is against the law.

Sometimes you wish you could just put someone's foot in their mouth for them... I had my children when I was 17 and 19. (Husband and father of kids had a 2 year old already too.) People ask me if I am married and have kids, and I get, WHAT?? HOW OLD ARE YOU?!?! HOW OLD ARE THEY?!?! WOW, YOU SURE STARTED YOUNG!!!!! Some people have nothing better to do then insert their opinions into other people's lives. We could find something in everyone of their lives to criticize too if we tried. I would love to see the look on someone's face, if when they said, "Oh you must not be very caring if you don't have kids.., " you would say, "Right, like how you must not be very caring because you're rude..." :) You are spending countless hours taking care of complete strangers, sacrificing many times your body and sanity in the process.... is that not caring enough? You'll do fine. Hang in there. They're still working on that "rudeness" vaccine.

Having computers in everyroom is priceless-- along with Micromedex (agree with whoever said that earlier). I can look up what is compatible with what in a snap right at the bedside. Also, LOVE having artlines to draw blood out of, and LOVE being able to run ABG's right on the unit in a couple of seconds. Not really gadgets, but I lose EVERYthing, so they are not worth buying!