wannabecnl

Not a mistake as much as just a silly choice for the writers: two weeks in a row on Code Black this season, the patient went into Torsades de Pointes (already a rarity) AND the resident failed to recognize it. Really? I learned that before I finished nursing school!

OP seems to have flown the coop, but I'll answer for anyone else looking for guidance. Just a few thoughts: 1. As a PACU nurse right out of nursing school, it was very important for me to have a lot of "uncomplicated" cases during my orientation because I needed to hone my process and learn what normal looks like... and there's a HUGE range of normal. I had a preceptor who wanted me to take all critical patients so that I could get over my fears about them, but it was sort of useless until I had a good rhythm going and knew what I was looking for. Once I could get through a case without going crazy, I was ready to start tackling the complicated ones because the background process was comfortable. So I agree with OP's assessment that some more critical babies would be instructive... AND the replies that you can't care for the sick ones until you know how to really care for the relatively well ones. 2. I have been working for 4 years now, and there are still things I learn on every shift. A colleague retired last year after about 40 years as a nurse; she always said the day she didn't learn anything new would be her last day on the job! 9 months, with all due respect, is not a long time. You will see that after you reach a year, 2 years, 5 years. There is absolutely no substitute for experience: nursing experience. 3. I would encourage anyone in OP's position to a) take a breath and enjoy not having a death-defying job, and b) make sure you have advocates in your department that will bring you over to show you the "interesting" (read: critical) patients and what's going on with them. I was a student in my unit before I worked here, so my coworkers STILL call me over to show me things I may not have seen before. I love it! In PACU we see odd problems so rarely that there's a lot of show and tell...

Yes, ask questions, but consider the source for the answers. Is it something you can look up? Is it a more conceptual question that is well-suited for your peers, professors, or preceptors? Is it procedural and well-suited for your clinical instructor? But ask them somehow, and if you don't understand the answer or don't think it is answering your question, reframe and start over. The reason I encourage you to ask questions is because I firmly believe that the definition of critical thinking is ASKING THE RIGHT QUESTIONS, of yourself and/or others. The real challenge lies there, not in being able to answer questions. If you ask me anything about my patients, I can either answer you immediately or know where to quickly look it up. But if I fail to ask the right question, I can't act on the things I am observing when I assess the patient. Here's an example: let's say one of my post-ops comes out with blood pressure of 172/90. The first question I ask myself is whether this number is accurate. I take it again. 168/90. I take it on the other arm and/or change the cuff size or location (if the cuff is too loose or too small for the patient, it will read high.). 170/88. OK, now I believe that it is really in the range of 170/90. It's not enough to leave it at that or blithely call anesthesia for a Lopressor order, though. I have to ask myself what could be going on and assess the risk of harm from each cause or treatment. What is the patient's baseline BP? If it's usually high, I may not want to risk tanking him unless the risk of a high BP is worse (for example, if he has a new vascular graft or underwent spinal surgery, I"ll ask the surgeon for some parameters). Is she in pain? I'll medicate her for pain before giving anti-hypertensives and can often kill both birds with one stone. Does he have a full bladder? I'll grab a bedpan or urinal--this is noninvasive and simple to try. If none of these work, then I'll call anesthesia to discuss anti-hypertensive medications, including asking what BP we're shooting for! Every decision you will make in a clinical situation is based on asking the right question and then answering it with your book knowledge, concepts you are developing in clinical, or actual experience with patients. By learning to frame questions early, you'll set yourself up to give excellent, informed, well-though-out care. Be curious. Think about what you don't know. Better to ask a question than make an assumption--"when you assume..." and all that. If you become a nurse who never asks questions (especially of yourself), you will be useless at best and dangerous at worst. No one knows everything.

I enjoy using SkillStat to refresh. However, I took an actual class in basic dysrhythmias in nursing school (extra offering from one of our professors), and that helped immensely to get me started with what was totally new material. You should see if your hospital offers a basic dysrhythmia class and take that first. As I've renewed ACLS and PALS over the years, I have had to take an online pretest from the American Heart Association that included rhythm strip interpretation along with meds and scenarios. You can't even take the refresher without passing the pretest, so it's not something you'll learn once and then set aside! You want to just practice them over and over again so you don't have to stop and think too long. You should know VF, VT, SVT, brady, Afib, and Aflutter with one look at the monitor. And don't forget that even if it LOOKS like NSR, you MUST check a central pulse to eliminate PEA. I found that rhythms made more sense in context (i.e., on a real monitor in my PACU) than in a book, but they have a lot of variability. Even on SkillStat, they only have so many strips to show you, so you want to look at actual strips. I print out and save the interesting ones to share with our ACLS instructor!

I'm a second-career nurse; I turned 40 during my first semester of nursing school and am now 46 with almost 4 years of experience. Here's a different challenge that surprised me: it's weird being the newbie in middle age. I have the nursing experience of a 24-26 year old, but I have the life/professional/personal/educational experience of my actual age, and sometimes the two don't come together. You will be expected to pay your dues, just like you had to in your first career. You are probably used to a certain level of authority and competence in your career, especially as you have been managing an office, and this can be tough when you essentially start over. The thing that has troubled me the most, though, is that friends my age from high school and college are very settled and established in their careers, achieving big things and enjoying the fruit of 20+ years in their fields. If you recall Erickson's stages of psychosocial development, you and I are both in the midst of "generativity vs. stagnation;" my friends (and husband!) are all generating like crazy, while I'm still on the treadmill of the newer nurse trying to get my employer to realize I have a LOT to offer from those extra years doing other things! I don't say these things to discourage you; I just wanted to put in my $0.02 with a different spin on what I have experienced as a second career nurse.

I went into nursing school expecting to end up in the OR or in psych. I found out through clinicals that neither was a good fit. I adored my pts at our state hospital, but they drained me absolutely dry every shift for the whole rotation, and I knew I would burn out in a year. Then on "OR day," when I watched an incredible surgery and realized that A) I like my patients awake, B) everyone else in the OR had a job that interested me more than the circulator's, and C) I could NEVER stand still long enough to be a first assist, that was it for OR. This left me high and dry without a direction. My clinical professor arranged for me to have a shadowing day in the PACU instead of another day in the OR, figuring it was surgical-flavored and a place I could actually interact with patients, and I WAS HOOKED. That was it; I've been there ever since. I would not have known this if I hadn't had the chance to go down there and hang out for a day. My advice? Shadow, shadow, shadow. If your gut says "forget it," listen to your gut. As someone pointed out above, knowing what you don't like is at least as important as figuring out what you do like. I tell everyone to shadow; you'll know quickly if an area gives you energy or saps you, bores you or terrifies you, makes you want to learn more, or (and this sounds awful, but nurses, you know what I mean) if you're even interested in what's going on with the patients! (For example, I LOVE doing preop calls, meeting patients before surgery, caring for them afterward, but I don't feed them, get them up walking, worry about their discharge plans, or care about their BMs. Sorry, it's just not my thing. Once they're upstairs, I'm grateful for the med-surg nurses who love that stuff!) Don't feel badly about realizing what you don't like; yes, you can always move around, but life is short, and I think you give better care when it's your thing.

Since we started this thread, I've been more aware of stupid TV medical errors than ever, and this season of Chicago Med hasn't disappointed. My ongoing favorite on CM is how the BP can be reading fine one second, the patient goes into some crisis, and maybe 5 seconds later the nurse/MD/family member says, "Their BP is crashing!" No A-line in sight, btw. Fastest cuff in the west, I suppose...

I've been in PACU for over 3.5 years, and I echo the sentiments above. With your ICU background, you'll do well in PACU, but the pace is different. I love the autonomy, the variety of ages and cases, and the "surgical flavor." I don't love call or feeling understaffed at the end of a shift when we end up having to discharge patients direct from PACU. There is good backup support from docs and a pile of nurses with more experience than I'll ever have (at least during the day; on call, the ICU nurses are our backup, and the docs are on pagers, but it's not the same). I love the patients; they range from infants to 90+ years old, and from wide awake and asking for food to completely schnockered with an oral airway in place and needing a jaw lift! Have you had a chance to shadow in the PACU? I'd try to do that so you have an idea of what it's like. Good luck!

I came to nursing as a 2nd career and have realized in 3 years that it is very, very different from the IT/tech writing background I had before. Then I had projects, near and long term goals, and actual advancement with more responsibility and new things to learn all the time. Don't get me wrong; I'm in a VERY nice position: per diem in pacu and preop, so I pick my hours, and the pay gets a little better each year. BUT, I do feel like a cog in a giant wheel, a cog that could be replaced in 2 seconds by another nurse cog, and it really wouldn't matter that much. Also, the realization that the 20- and 30-year veterans are doing the SAME WORK I AM DOING is starting to bother me; in 20 years I should be doing more than I'm doing now, right? I do hope to move into a research role eventually, and I know some nurses get more advanced degrees and go into management or NP/PA work, so I'm probably not the only one.

Every episode of Chicago Med seems to involve a chest tube. Every single one. They use etomidate and succs for EVERYTHING, too--I've been in PACU for 5 years and I've had exactly one patient that got etomidate for induction. And how is it that Colin Donnell's character can so seamlessly move between ER/OR/and now transplant? He must have trained at General Hospital. The monitor inaccuracies make me nuts, as someone posted above. Pulse checks while pt is getting compressions. On Chicago Med and Code Black, their compression rate must be 140 at a minimum, and yes, those wonderful bent elbows look so nice and would NOT WORK. But I guess they'd break all of the patient actor's ribs if they did it more authentically! A few episodes ago on Code Black, a rich donor's wife was lying ALONE in a dark room, having not yet awakened from surgery, when he came to see her. Uhh, PACU? Stay with the patient until the are CONSCIOUS, maybe? Just a thought if you want that money to keep rolling in. One real question for our ED people: how long do codes really go on in the ED before they call it? For a witnessed arrest or close to it (usually the case on TV), they seem to give up very quickly. Of course, no one is doing the 2 minutes of compressions between shocks/epi/etc., either. I know how long 2 minutes feels in ACLS class, and I don't think the TV producers would allow that...

I had a friend who worked many years in the ED and switched to school nursing for a better schedule and benefits. I think she spent a year or two before she was back in the ED. Not that this would be your experience, but I agree with posters above who recommend that you keep the ED in your back pocket as a per diem. I do wish you luck in endo!

Next month I'll be embarking on my first stint as a camp nurse for a winter weekend teen camp. I know the camp well but have never volunteered there. I work PACU, which has its camp-relevant aspects but is nothing like being a peds nurse or school nurse. I bought a first aid book and am ordering Erceg's book, but I am wondering if I should try to find a quick Red Cross first aid class. I'm also used to being about 6 feet from a crash cart and an instant page from anesthesia staff. So, what else can people suggest? This place has a tubing hill and I foresee twisted ankles and frostbite...

I've only worked PACU, and I always chuckle when a well-meaning AN member sends nurses our way for less stress and an easier job! :) There are stressors and stressors. My schedule is wonderful, especially as a per diem; we don't work overnights or weekends unless we are on call. The pay is the same as elsewhere in the hospital, and I have 1-2 patients at a time. My patients are all on monitors, and I have a room full of ACLS/PALS trained people to help in case of an emergency. For the most part I don't deal with families, and we have a great rapport with our anesthesia team. Lots of autonomy, variety, and challenges. Preop procedures are fascinating and always changing, so we learn new things all the time. These are all VERY GOOD things about PACU. But any patient at any time can go south. It isn't the ICU, but it is critical care. We train for the worst and then wait for it to happen, and some skills get so little use (hanging blood comes to mind, along with drawing blood samples off a PICC, the really picky drips like Cardizem, etc.) that we never get that comfortable with them. Scary airway issues. Alcoholics waking up in a rage. Toddlers waking up in a rage. The rare patient going back to the OR for a complication (it always seems to take forever to get them back in there). These are stressful for me but less so for the more experienced nurses among us, so maybe it's just a comfort thing or my personality. For me, it is worth the trade-offs at this point. In the future I'd like to focus more on periop research and evidence-based practice, which would keep all the good stuff and lose some of the bigger stressors! Although I'm not sure why I get stressed, since all we do in PACU is watch people sleep...

My heart is with you. I am so sorry that you have experienced this, especially since it was not a one-time thing but a pattern of stress. I can't imagine working in a CV unit without some method of debriefing. We had one code in PACU when I was a student, and that is such an incredibly rare occurrence that I wasn't surprised we didn't have a debrief, but that doesn't mean we didn't need one. Just because it's a common occurrence doesn't mean people "should get used to it." You have a wealth of knowledge, and I hope that you will redirect your knowledge and experience into a different nursing area. You don't have to work critical care; you'd be an asset in any area. Do seek some help, and don't give up on nursing! Heck, you'd be an amazing mentor to new critical care nurses or could help develop programs to support nurses in high-stress specialties. Maybe a longer article for AN? Good luck to you.

I did my immersion and final capstone project in PACU (and work there now). I bought Cecil Drain's book "PeriAnesthesia Nursing: A critical care approach." I didn't read the whole thing, but it is an excellent reference. Keep track of the meds your hospital uses, and don't be afraid to ask the anesthesia staff what something is so you can look it up later. They'll be using IV pain meds, antinausea meds (IV plus scop patches and po marinol), drugs to raise and lower BP and HR, and anesthetic agents. You probably already have a good drug reference guide (I like my Davis). Use it to see the various dosages, cross reactions, etc. It's impossible to learn every possible surgery beforehand, so see if your unit has a copy of the Core Curriculum (they should know what this is). If you can take 5 minutes when you know what patient you and your preceptor are getting, look up the surgery and familiarize yourself with the issues, terminology, risks, and outcomes. VERY useful. Ask your preceptor if you can follow the same patient through the whole process, maybe one outpatient and one inpatient coming from/going to the floor. It is useful to see the whole continuum of perianesthesia nursing care (preop, surgery, phase I recover, phase II recovery or inpatient admission), which starts before the patient even gets undressed and continues until they are discharged. Where do you work? You should visit the ASPAN website, which is Home (I don't know why AN makes this into a hyperlink called "home", sorry), and find the local component close to you. Attend a conference. You won't get CEs, but you'll learn something new and meet other PACU nurses. Some of the nurses in your unit may be ASPAN members and/or active with the local components. That ASPAN website is a great resource for practice guidelines, too. I love my job and learn something new every day. I hope you will enjoy it as well!