nightengalegoddess

Wow. Thanks you guys. Is it mostly children that are being cared for or do you also have a population of elders/quad/para/...etc? Yes, I will continue reading other posts within this specialty section. Thanks!!!

As said here; there are standing protocols for ordering common needed things such as the ABG. Often standing order sets exist which make this practice ok under hospital policies. The well- seasoned and respected RN ordering in this fashion with or without standing orders probably has long-standing relationships with the physicians such that she knows what to order, why, when. But you are new to the ICU; and usually there is a physician quite handy for whatever happens. Why not just run it by the physician first? As already said; you are notifying the physician of change as well as allowing the physician to call the shots. It is the physician who is practicing medicine. In the end, it is not the RN who ought to be practicing medicine. That is really out of her scope. I would, as said, familiarize self completely with the order sets, hospital policies and protocols; and go from there. Sometimes it is just better to follow the rules no matter how irritating it may be to a physician or an RN. Of course in an emergent situation, an RN must do what is needed for the safety of the patient. But in reality, how necessary is it to order a KUB if there is no standing order without the physician knowing that a change is happening? Protect your patient, protect your license. Let the physician practice medicine and let the RN practice nursing. In the ICU it is necessary to be able to think like a physician, but we still need to act like an RN; within our scope. And being new, I think it best to develop your own practice within scope and with caution. The RNs who are always talking about how stupid, slow, inane some physicians are; and how they would make different medical decisions really bug me. What is wrong with being a nurse? If a nurse doesn't like being a nurse, then go become a physician. Oops maybe that sounded harsh. What is wrong with, "Dr So and So, I have a feeling something is going south with Pt. So and So because of this and that, (or just because I have a gut feeling).Do you think we ought to get a KUB, blood gas, (whatever it is you think should be next)..." that shows you are thinking critically without taking the physician's job as your own. Maybe I'm wrong. But of course in reality, if a patient is swinging, spitting, and endangering self and staff I would have no problem using soft restraints before I called the physician for an order. So there you go....grey areas. In the end...ask yourself....what would the BON do?

A "magnet" hospital and this particular ICU had previously rarely had the charge nurse take patients. There are plenty of float staff and RNs willing to work extra shifts; but now it is becoming common for the charge nurse to take her own two patients as well as having two patients while one may be on CRRT. Understood, this is a cost saving strategy. Although in the long term, can only lead to legal issues in regards to safety, obviously. Which seems much more costly. I'm probably naive, but how common a practice is this? Of course, this state does not have a union. Otherwise I am sure this would not be happening. The problem is that when something does occur; i.e.: an RN has to go home because of their own medical emergency, there is no one to care for the patient/s for hours because of this kind of staffing practice. Besides the obvious problems with this practice; being just impossible to properly monitor an entire unit (this one with 28 beds) as well as provide good care to the two patients of the charge. I've seen it quite commonly on less acute units...but the ICU!!?

Just....what's it like? Is it terribly boring to hang out for eight to 10 hours at someone's home ? Of course you are doing your nursing process and duties; but compared to the 12 hour shifts of an ICU.....what happens between repositioning, cleaning the patient, turning them, suctioning them, assessing and monitoring, giving meds? How close do you find you get personally to the patient and the family? Are your professional boundaries challenged? Are you able to provide the therapeutic relationship ongoing without having conflicts arise around professional boundaries? Any information would be appreciated. Myself, worked within hospitals for my entire career most recently ICU. Know private duty is less money but not interested in money much anymore. Being able to feel calm and actually help people would be nice.

Been doing ICU for about 18 months and yes, still feel overwhelmed at times. A lot of ICU nurses don't like to hear this. But one of the things that has saved me...(.because I have over 8 years of medical/surgical/telemetry experience prior); is to remember that ICU nursing is the same as any nursing but it happens faster and there is more of it. More technology to learn, more evidence to compare, faster impeding death, etc. But we are still doing the nursing process; same as it ever was. And yes, I still feel afraid and stupid at times. I am getting used to feeling stupid. That helps. It is difficult to come from an area of nursing where you feel you can go no further, and then get into ICU where you feel like a new grad all over again. I am still very humbled by the transition.

Simple question: How do you personally get other nurses to customize their monitor alarms when it becomes brutally obvious that it is not necessary to alarm with every PVC pair....or that the baseline is a wide ST....etc" I find it difficult to verbalize how much others' alarms are driving me crazy all night at work. I don't mean the alarms that we know are necessary. I mean the ones that will never change on a patient.

Yes!!! Great article!!!! Please everyone....we do not need to respond to your PAIR PVCs all night long! Please, customize that monitor or fix that patient! Have courage to customize!!!!

It is clearly my experience that nurses of higher levels are resources for the unit they provide service in. They mentor (although inherent personality determines how well)....they can easily care for the more critical patients; and I do believe...their experience is worth more money. And I am stuck at level 2 because of lack of motivation to do all the extracurricular stuff. I am happy with my wage. I earn it honestly....as I feel the level 3/4 does. When first starting in ICU I had a terrible preceptor who was all image and no teaching ability. She is still worth level 3 because she has the smarts and action to do what is needed when a level 2 is new and doesn't know what the heck is going on yet. She can reflexively take over. That is why she should be paid more. Taking care of a stable pair competently....even excellently.....is nothing close to taking care of a highly unstable patient with a chance to survive. That is why they should be paid more. Of course there are the level highers who just want to mentor all the time and are crappy at it so they can have an easier shift. But hey.....good with the bad. When push comes to shove they can still be the brains to move the situation even if the brawn is lacking. This is truly my opinion; and I live in a non-union state and am planning on moving into union advocacy within the next few years in another state. People need to be paid for their experience. It is fair. If assignments are lax and unfair, that is the particular institutions' fault and yes.....they ought to be struck for that. Careful research needs to be performed on these to decipher which are abusing this concept.

Thank goodness this therapy is back in fashion. It makes sense and shows results. Our hospital is cheap with the rotos.....so as said....bundle up the team.....secure the lines....and get creative. I know our patients are often over 300 lbs....but treat their bodies just as you would a baby and move their lungs around. It just takes teamwork.....as mentioned......pillows......logrolled blankets.....and lots of laughter.

Don't know if you, poster are still reading here....you have probably gotten homey by now...because it sounds like people like you . That is the most important thing, I have found, in ICU. That your team feels they can rely on you to help in whatever capacity you can. As said, your higher ups would have told you if you were unsafe. I am a very private personality. I also have spent years in med-surg areas where we are on our own. I had a hard time joining the group...only child syndrome. Even though I was competent, those I first worked with doubted that because my personality is so quiet. I didn't do enough "hey look what I did tonight!" stuff. You are lucky. They like you. That is the main thing. There will always be those who challenge you because perhaps they are distrusting, as mentioned, or just burned out or mean. Let it go. Unless the manager has you in there.....keep trucking. I had to learn to be louder, brag more....express darker humor......and when pulled into CNL's office.....continue to ask....."have you looked at the charting?"......and "this is what I have learned from the AACN"......I also had to transfer to a different ICU because I was being picked on without real evidence. I had to get out before they got me. No clinical evidence was brought up but my introverted personality made me suspect of weirdness. You are well liked. That is mostly what ICU nursing is about. We all learn expertise ongoing. It takes a lifetime of career to do what you want to be doing right now. I felt the very same way. I've learned to be very easy on myself. And I remember that very few people are willing to even try to do the job we do;much less step foot in the hospital. I try to remember that as long as I do no harm.....and hopefully do good...(more good in more time).....I am being all that I can be. As a private person.....I have learned to talk small talk even though it does not come natural. I have found my coworkers will trust me more when they feel I am not isolating myself as I had to do on Med Surg to advocate strongly and survive. Everything we need for out patients is at our fingertips in ICU. It is the best and most privileged place to nurse as I see it. Make sure to take advantage of all the resources. No question is stupid. The more questions the better. I know it will in time become second nature. Yes, report can be weird for some weird nurses. Just give your report. They need to give you respect and listen. You do not want to be responsible for something unsaid because they are laise' faire and/or just seasoned. If something goes south and you did not mention it in report out of intimidation.....that is on you. So suffer slings and arrows of narrowed eyelids for your ethics.

I'm sure that you are a member of AACN. That will plug you in to everything in the now/know. You are doing everything right so far. Experience and asking lots of questions of those you see as capable.....as well as buying the books and reading......and tincture of time.......if you are near a teaching hospital.....grand rounds! usually get the free lunch too!!!!

I explain clearly to family and patient certain results are legally beyond my scope to discuss before physician discourses with them. I also tell them after physician has diagnosed/analyzed and discussed, any questions may be directed to nursing staff. If nursing is able to legally discourse......we are their resource. I want them to know there are legalities associated with what we can tell. Because as we know....sometimes docs do a poor job of confrontation when failure is imminent.I don't want pt/fam. to think I am withholding what they need to know....I want them to know that I am bound to parameters. Most of them don't have an idea of our job. Of course, I don't say it like that....say it differently for who I am speaking with! If the patient is from the projects....I use their colloquial ( sp?) terms....if they are college professors....I try my best to sound like an English major. Ya know? Just explain it after it is diagnosed. We can't diagnose. We can educate. That is the scope/parameter. As said....if pt./fam. is already tracking and understanding of certain flows of results and meanings per previous discourse with physicians....then...yes....honesty. Bad news.....your face can transfer a lot of info. Your tone can transfer everything they need to know. The physician will say the words. We will deal with the aftermath. That is our job. To tidy up the heart , soul, and mind of the world gone wrong. Also...for my practice (nights)....always still try to educate from get-go, so bad news will be noticed by family themselves to soften the blow.. EX:..If physician is AWOL for a while and pt/fam. are anxious; and I know in my mind that some result is not positive for analysis of whatever diagnoses/trend they are worried about....I often say something like...."as a nurse I work with signs and symptoms..the physician is the only one educated to give you the full story....but I can tell you that if something were terribly worrisome, the doc would be here right now.......so let's just work on keeping you comfortable and let me explain what I am going to be assessing and monitoring related to the results that I have seen." And I tell them all about the numbers and colors on the monitor and what parameters we are trying to achieve and why. Most people are really freaked out by the monitors; I have found, and a little education on what the heck we are staring at when we gallop into the room really helps them contribute and feel empowered to help. Family often become my help mates. They deserve to have some control by learning that every alarm doesn't mean death is at hand. They seem to appreciate what we do more when they know what we are watching and why. And they can tell me...while I am admitting next door...."hey ya know....that number has been going below 90%......do ya think we should try something?"......I actually LOVE when everything comes together like that. Excuse my excitement. 10 years as RN but 1 year in MICU and STICU......still amazed with the intimacy and collaboration of it all. If family and pt is willing...they are part of my team in any way possible. BUT NEVER shall the RN (well, me) allude to diagnosis before the physician. That is my line. I know I am not educated enough to do that. I don't want that responsibility either. Also, being pretty aggressive with physicians to "get the heck into the room before the family freaks out"...is something I will do freely....and animatedly...........thanks for letting me get all excited.

OMGosh. Been a stellar Med-Surg-Tele RN for seven years, been also inpatient rehab.....now trauma ICU.....just like a new grad again.....can't imagine being a new grad with no guidance in ICU!!!!GEEZ!!!! Good for you and your license (alas for the rent/mortgage, etc. right now)...this too shall pass. Hugs.

Thank you so much Hodgie. I am not too far afield in my assessments in the trauma ICU by reading your response, (just a little unconfident). But this has helped much!!! Thank you Jackie too! Luckily, our R/Ts in general are helpful, experienced; and I have found very non-egoistic. Some have stated they wished for more RN input often. This information is well taken. I thank you so much.

Thanks Sun. The thing us RNs do with the vents is titrate the FIO2 only. Thank goodness we have so many amazing R/Ts! A question for you as the RN....how much do you stay aware of the changes in the vent r/t your blood gas results; and how much discourse do you initiate with the R/T and docs regarding changes, response affects? Many of the RNs on my unit seem to almost ignore the vent settings completely and hand this over entirely to docs and R/Ts. Although I would love to do this....(so much learning needed in this area); I still feel like when I have an order (which is often) for the RN to mess with the FIO2, than I need to have some kind of at least elementary understanding of what is expected to change with the patient. A few seasoned ICU RNs know every little thing. I try to pick their brains when I can, but they work opposite shifts than I. And to tell the truth, my brain goes into tilt when I try to understand all of the factors! What does the average ICU RN focus on when interpreting the gases and the vent settings? How bout you? Again, thank you so much for response!