ShyViolet

Phenylephrine is a very dangerous vesicant which can cause severe necrosis of the tissues if it extravasates; therefore, it is always to be administered via central line. That being said, I have had occasions where a patient was crashing and all I had was a peripheral line. In that case, I have given the phenylephrine peripherally, but only until central access could be established.

If you were giving the medication, I don't know of any possible way they could prove that you weren't. It becomes a case of their word against yours, and neither one of them was there for the weekend to observe you giving or not giving it, correct? I don't think there's a whole lot they can do to you.

Congratulations, you're a registered nurse!

I passed in 75. What I hated was that it just shut off. No "Thank you for testing" message to let you know it was over. I sat in front of the computer for about 5 minutes about to cry because I thought something had gone horribly wrong! I got too many pharmacology questions, especially psych meds, so I thought for sure I had failed. Thing is, even if you don't pass the first time, it's not the end of the world. It doesn't mean you won't make a good nurse or that you don't know anything, it just means that you didn't take the NCLEX very well the first time. All a standardized test really measures is how good you are at taking that test. If they had had some EKG questions, I would've kicked tush all over that test.

I used to ask questions before I did pretty much anything! I got teased about some of the things I asked, but now that there have been a few newer batches of nurses coming to me with questions I feel like I'd rather know that they feel comfortable and safe to come to me if they aren't sure. Quality patient care is at stake, and I don't think you should ever feel like you aren't allowed to seek help with that. It was good of you to ask for assistance on the straight cath if you'd never done it; I don't think catheters are hard at all now, but I still remember the days when inserting a Foley seemed like the scariest thing I could possibly have to do!

When I was 6 months in and feeling like I wasn't good enough yet, one of my preceptors gave me this breakdown: 1st year: Task oriented. You are all too aware of the clock ticking and you know that you have to assess your patient, do vitals on schedule and get meds passed on time. Your main question is "What do I need to do to get through my shift?" 2nd year: Numbers oriented. You're starting to understand your assessments a little better, starting to put the numbers together and understand what it all means. Your main question is "What do I need to do to fix these numbers?" 3rd year: You're finally a holistic nurse. You know the numbers, you know the norms, you know what to do in a lot of situations. Now your main question becomes "What does this person need me to do for them?"

Being told that a patient had no TF residuals for day shift, only to get 6 hrs' worth of residuals when I check. When a pt has been intubated for 3 days and nobody has cleaned up the orders to change the PO meds to something else (especially for enteric coated meds that can't go down an OG tube), then the doctors look at me like I'm crazy when I ask them to fix it. When pts get annoyed and start refusing ridiculous things like temperature checks and lung auscultation. Listen, I know you are tired and don't feel good, but when you're in for pneumonia or sepsis I need to know if you're starting to show signs of infection again! When I look at past vital signs and somebody charted the DP and PT pulses as bilaterally present on a patient with BKA. When somebody reports skin breakdown to me, but it's not mentioned anywhere in the charting. If the first time it's mentioned is in my assessment at the beginning of my shift, and I'm the one who got the ET consult and did an incident report (which are both hospital policy), and the patient has a stage 2 decub, then you're going to look pretty negligent if anybody cares to audit the patient's chart.

Anybody who is on an insulin drip needs to be in an ICU, period. Q1h sugars get hard to keep up with even there; when you have 5 other patients to think about then either sugars will get missed or some other patient care will get missed. The patient who still needed a lot of inotropic support with dobutamine needed to be in an ICU; you should never have to take titratable drips on the floor, it's just plain not safe. And the lady with low urine output in possible shock? She at the very least needed to be part of a decreased ratio. Good candidate for an ICU as her vital signs seemed to be deteriorating. That was a very unsafe patient load, and it's not right if the nurses on your floor routinely have loads like that.

When I get a good blood sugar from one of my little grammies, I say "Awww, like I thought. You're perfectly sweet." When DTing patients start yanking their Foleys I say "If you yank that thing out then we'll need a urologist to put a bigger one in" or "If you pull that out then you can kiss goodbye all the good things your member does for you." "If you could sleep at night in an ICU, you might get too content and never want to leave" or "We have to make it miserable. It motivates you to get better and leave." When delirious patients claim they've called the cops (we don't have phones in our ICU rooms) I like to say "That's fine, I'm the judge's favorite niece." "I'm going to put a cool, refreshing stethoscope on your chest and make sure you've got a heart." After having taken care of a man in end-stage liver disease every night for several weeks and only speaking to his wife on the phone, I finally met her one night when she stopped by after work. I introduced myself by saying "I'm the 25-year-old blonde who's been spending the night with your husband." I once introduced myself to a lovely little old man and said "I'm just going to have to give you a little look-over and you can go back to sleep," to which he replied "Fair enough, I'm giving you a look-over right now." When men ask if something will hurt, I say "No more than childbirth, and it'll be a lot quicker."

Could you PM me the information as well? I've recently become interested in the PHRN certification.

Getting into a casual or per diem position might help get you a foot in the door. I would take whatever I could tolerate in the hospital setting just to get in; once you're in-house it's easier to move than it is to get hired in the first place.

In my experience, nurses who are only doing it for their required CC experience don't work out well. It's good to have CRNA school as a goal, but take the ICU experience for what it is. The ones who are only viewing it as a bullet point on a checklist forget what it means to be a nurse and care for a person.

It's definitely OK to change sensitivity and output as needed, because you're not changing the actual settings; you're making the settings work the way they're supposed to. I do check the underlying rhythm, unless I know that there is something deadly underlying. If the patient is able to take the pacer being off for a minute without decompensating, I might take a moment to check the blood pressure and cardiac index with the native rhythm.

Somewhere in your assessment notes it should state that your a-line is giving a dampened wave form, so there is no reason to chart bad data. As another poster stated, lawyers adore charting discrepencies and having two different pressures in the same set of vitals is a heck of a discrepency. If your art line is no good then you should talk to your doctor about either getting a new one (if you still need it) or discontinuing it.

I have seen both heart and lung transplants kept fairly dry for the most part, with inotropic support for MAP and CI. Our surgeons' drug of choice for this is usually either epi or milrinone or some combination thereof.

Current nursing research does not support this. If you have an arterial line with a good wave form, properly zeroed and calibrated, then you have an accurate directly measured pressure. Who cares what the cuff says in that case? If they don't correlate, then which one are you going to use? I only chart the one I'm using for titration of my drips. As soon as the patient is stable off drips, we try to get rid of the a-line as soon as possible so that we can eliminate that pathway for infection. Again, there have been studies into this practice and really it's an unnecessary step for the most part. If you have a good art line, then you have a good pressure. The cuff only becomes a relevant measurement if your arterial line is over/under dampened (in which case your cuff and line won't correlate) or if you're going to get rid of the line or cap it for patient ambulation. For legal reasons, only chart one or the other. I was taught this by a nurse who was involved as a witness in a lawsuit against a hospital, and the staff were thoroughly interrogated on why they were charting two blood pressures that didn't necessarily correlate. You might have a cuff of 137/58, and an ABP of 72/66. Which one are you trusting? If the ABP is dampened and inaccurate, why are you even charting it? How do you pick and choose which one is good? In a word, don't chart bad data. It can only hurt you later.

Ask a ton of questions! In the ICU, we are more annoyed by new nurses who don't ask. We know you don't know everything, and it terrifies us when people don't seek the knowledge. Be a pain. I was and still am at times. Communication is key; your charge isn't in the room seeing everything. They may not know that your patient is crumping unless you tell them. I have had many double assignments that had to be broken up at change of shift because one patient became unstable enough to be singled. Read, study and learn. Take the time to look up your meds. You'll probably have a lot of drips linked in a chain of stopcocks, so take the time to learn what's compatible and what isn't. Learn to read EKGs as soon as possible, and bone up on your neuro assessment skills. What sort of ICU is it? It's not a bad idea to show up a little early for your shift to find out what your assignment is. This will give you time to look up diseases, surgical procedures and meds before it starts cutting into your day. I used to come to work an hour early, and still usually show up about 30 minutes early. Not everybody does, but I like to start getting my head in the game so that I am not starting out in a panic. Finally, trust your gut. If the patient looks bad, get someone. It's not a crime to ask your charge to come in and give you a second opinion before you call the doctor. I have frequently sent ABGs and called the MD just because my patient seemed spaced out or out of sorts. Sometimes it's nothing, sometimes that was how I discovered that a patient had stroked.

Even if you are still on orientation, it is better to move now than to wait. If you don't want to be there, you're not doing anybody any favors. If you're only a few months in, it's still early enough to bow out gracefully. I would just make sure to talk it over with my preceptor and unit educator to ensure that you don't burn any bridges and that you communicate why you're interested in transferring, as you will probably be relying on them for a recommendation to another unit. I work in an ICU myself; I started as a GN and the learning curve is incredibly steep. But it is manageable. I feel like I use everything I learned in nursing school every day, and two years later I still spend part of every day looking up something I'm not familiar with or looking more in depth into something I already knew about. I still come home and read my school text books so that I can learn more about what I'm doing. Med/surg nursing can be a good way to learn basic skills and organization, but they way you organize your day in the unit is completely different from the floor.Just because your patient load is smaller, doesn't mean that your workload is. There is almost no room to delegate tasks, and you have to do very frequent vitals and assessments. The two are really very different worlds and being good at one doesn't necessarily translate to being good at another. I've seen incredible ICU nurses start out as GNs. I've seen experienced floor nurses who go back to the floor before they finish their ICU orientation. And I've seen every situation in between. I personally had, and continue to have, zero interest in being a med/surg nurse. Critical care was the reason I went to school, and it's my vocation. As far as patient interaction, I have the happy obligation of reassuring patients and their loved ones during a time of crisis, and helping them to gain the knowledge they need to help them through it. I see so many situations, and I have to tailor my approach for each family. Whatever you choose, we need more nurses in the ICUs and on the floors who understand that patient interaction, and treating a person (not a problem) is the heart and soul of nursing. It's what makes us what we are and not just doctors' servants.