imnmk_rn

Ruby Vee, you have the most hilarious stories! I'd love to just sit around talking to you about old nursing stories! It seems like all the best stories come from you! Thanks for sharing!

Well, I have to say I am used to computer charting - and we are in the process of changing to a different application and changing to an entirely computerized medical record (right now, MDs still write progress notes and orders on paper, and we have a paper Kardex and plan of care, but the rest of our charting - vitals, assessment, I&O, meds, etc is all in the computer). And honestly, it's what you're used to. Even though the program we currently use has its bugs and has annoying things, we are familiar with it... but going from one system to another, everyone is having a hard time with. Any change is stressful - but take it as it comes, roll with the punches. Here are some of the positives of computer charting.... -Computers that interface with your monitor... example your vent settings, HR, BP, etc come over into the computer when you click on the time. Very nice for those q15 minute vitals! -Reports that pull lots of info together - being able to see I&O graphed for a certain number of days with weight; being able to see from your MAR not only what the pt's recent blood glucose measurements have been and insulin(s) they have received, but also how much D5W they are getting in their various IVs, what you've charted as their diet, etc. -Multiple people using the same chart at once (keep in mind, most charting systems make it impossible for two people to document meds at the same time) -Calculations done immediately for you - I and O data, drip rates, weight change... Yes, there are downsides to computer charting. And it IS very annoying when it slows down or goes down altogether... but then we are all complaining about the paper charting that the majority of my coworkers and I are not familiar with anymore, since it has been so long since we've had to do it... Go with it - it's the wave of the future. And smile... there are worse things that have hit the scene. Like I said, any change is stressful.

Any advice on surviving the unit as a newbie?? I think I made the right choice though!! :wink2: I also started in critical care and like you, felt it was the only area I really really wanted to work in. Someone just asked me the other day if I wished I had gotten other experience first and my honest answer was no. But here's the deal - you have to be open to learning every single day... ask questions, ask if you took the appropriate approach, seek out the people who are sensitive to the fact that you are new and who are willing to help. I believe I have learned the most on my day shifts - because like you said, it is busier, more procedures, etc. You know what else I loved about day shift? Picking MD's brains about what we're up to and why they ordered certain things. My one other piece of advice is to develop tough skin and accept constructive criticism willingly, but let other things bounce off you!

Did you have an order? Did your coworkers think you couldn't independently decide a pt needed a 3-way? I don't know why inserting it would be out of your scope of practice, but CBI without an order probably would be.

I touched on this on a post on family visitation... (I guess I'm being wordy tonight) I have had three experiences with families present during codes - two bad, one very good. Honestly, though, those two families probably would have acted almost the same if they had shown up after the code. Screaming, yelling, falling down on the floor, running up and down the hall just happened to be their way of dealing with it all. I can't say they wouldn't have done that if they hadn't seen the code. I don't know if it helped them accept the death or that everything was done. A few questions I have for you - who are you planning to have accompany the family into the code to explain? A designated person (and if that person is not available, will someone automatically step in)? And are you addressing this with families the minute the patient hits the unit so you know what they want? I just read an article in Critical Care Nurse on this topic and it advocates knowing what patient and family desires are ahead of time... how realistic is this? How are you planning to deal with "crowd control" issues? (We have enough of a problem with all the clinicians that gather without families in the room too - some rooms just are not large enough.) I only ask these questions because I'm curious how you have dealt with it or how you plan to deal with it - I think in theory, it's great to allow families but I would like to have a plan in place for the realities of patient/family situations. As far as the great experience I had with a family member present at a code - it was one of those times when in the very short time I cared for the patient (all of two hours) that were entirely involved in crashing and not making any headway, I had one of those days where I really felt good about my job, both the physical care for the patient and the care of the family. It helped that I got a lot of positive feedback from many people, as the patient was a radiologist at our hospital. I was working with two of our absolute best intensivists and an awesome pulmonologist who were essentially at the bedside the entire time, and I had the backup of top-notch nurses a few feet away even when they were not at the bedside with me. The patient's wife stood at the end of the bed, with one of the MDs and I kind of taking turns explaining things as we were able, and just having an ongoing conversation about where this was going, and the moment we had the crash cart there and were ready to code the guy, she said no, to just let him go. Then I had the (unique, at least on my unit) chance to spend the next few hours with my patient's family and doing all the postmortem stuff before I had to take another patient. I was able to meet other family members, and was able to be with the patient's wife as she brought her 5 oldest kids (ages 5-17) in to see their Dad after he had died. It was like nursing in the ideal world with ideal docs and ideal families.

wow, I can't wait to hear more stories... I think! Off the top of my head, I am just thinking of my worst float ever - to one of the other ICUs in my hospital. Anyway, one of my patients that evening was a woman who had been there for a long time and their staff was sick of the family issues. The decision had been made that afternoon to withdraw care and make her comfort care. The first thing I realized was that the family was obviously not all in agreement - at least as far as the timing went. Anyway, I went to "peek" into the room (an old unit without glass in the doors, so I did have to go in to see what was happening with the patient other than the monitor) and to see if pain meds/other comfort measures were needed at the time and I couldn't open the door because of the children sleeping on the floor. There were somewhere between 20-30 famiy members crammed into the room, coming and going at will, one of whom sticks out in my mind. He was the 19-20ish year old grandson, who needed to be "in control" of something and was determined to know where everyone was at all times, what they were doing, and basically wanted to coordinate his grandma's death. I don't know how many times in the first hour I was there he asked if she was doing "pretty good." Anyway, as my luck would have it, the woman died when he was out of the room (actually he had gone out to get someone who had gone out for a smoke, as he determined it was time for them to be in there). Upon his return to the unit, he was pounding walls/throwing things because she had died when he was gone, and somehow he ended up with a bloody nose and then barricaded himself in the bathroom attached to the room. At least though his family did not manage to calm him down, they did manage to remove him from the situation. Meanwhile, another granddaughter (early teens) was crying, while one of the adults was yelling at her to "Quit your crying, your grandma wouldn't like you to carry on like that," and others wondered if they could get a tray or just a sandwich before they left. Anyway, nowhere near as "exciting" as the other stories. But the best I could come up with at the moment!

What patient population do you work with???? As I have known some to call it, "vitamin A" is quite the wonder drug, at least in the ICU population! A little Ativan can go a long way as an adjuvant to pain meds, can be extremely effective for nausea, and is a must-have for DT's! "not safe to use prn..." under that reasoning, a lot of meds (narcotics) are not safe to use - many other drugs can develop dependence, too.

First, I work in a busy (who isn't...) 30-bed med-surg-neuro ICU in a large metro area in the middle of scary neighborhood. We are open to visitors 20 hours a day - we close for an hour at a time during change of shift (07-08, 14-15, 19-20, and 23-00) which is quite often not at all well received by acquaintances/friends/sort-of family, but usually received okay by immediate family (except some who will never be happy - we all know who they are). We do make exceptions - comfort care/out-of-town visitors/pt just got there or got stabilized - but make it a point to inform people that it is an exception and that this will not be accepted in other circumstances. In my experience, there are plenty of people out there who ruin it for the whole population. I am very glad that we close when we do, and I am very comfortable asking families to leave when I am doing cares/assessing the family - and always go and get them when I am done if I have told them I would. In a perfect world, open visitation is a wonderful thing. But in REALITY, I do believe that if we are not able to stand up and give pts their privacy, do the care we need to without interruption, and play these situtaions by ear (as far as pt needs, family needs, and how appropriate families are acting), patient care is compromised. Just a few specific tidbits that came to mind... all three ICUs in my hospital had tried totally open visitations with no restrictions. Mine was the first to institute any restrictions, and the other two have followed suit as they found it to be too chaotic especially around change of shift time. After reading the article about pt satisfaction scores, I wonder how HIPAA fits in... this article says that people were dissatisfied with the information they got. But I have to be careful that I don't even tell the wrong person that the patient is even a patient in my hospital to protect my license and the patient's confidentiality. Interesting story recently - a patient was terminally ill and had a very dysfunctional family. Had a specific list of family members who could see him/have info. He died about midnight with all of those family members at bedside. Between 04-07 (and probably more on day shift, I don't know) we received at least 5 calls from "family" who were not on the list inquiring how his night went. When told they needed to talk to his immediate family, we repeatedly heard, "but I am family, how was his night?" These people would say they were dissatisfied with info - but at pt's request. Okay, so a few other problems I have with some (not all family members) - I have more than just a few times had family members turn off my patient's vent and monitor alarms "because that's what you did when you were in here and told us not to worry because he/she was coughing." And that is keeping your family member safe???? How will that stand up in court when you sue my hospital for allowing your family member to die and I don't have proof that my "negligence" had more to do with you touching things you shouldn't have? As far as codes go, we don't have a full policy as far as I know, but play it on a case-by-case basis. I have had three experiences of families being present - two of which were bad experiences, all three codes which ended in the pt dying. Screaming and yelling and falling down on the floor in hysterics are what I mean by bad experiences. The one good experience happened to be the patient's wife who was well-prepared that this could happen and immediately said that we needed to stop and let her husband go. Re: pets - we have an infection control policy about pets visiting and as long as they follow the policy, we do allow them - I have had one patient's pet visit her. It helps that we have glass doors and she happened to be in one of our negative airflow rooms so we had two sets of doors that helped us feel like her cat wouldn't get out if we needed to walk in. Her son brought her cat a few times - and it was always fine. Actually, the poor cat was scared of everything and hid in the corner the first time, really didn't disturb anything - but this patient was relatively stable, too. It's sad to me that the horrible family experiences are the ones that stick out in our minds. I wish I could say that I was always positive about family members - usually it's really not detrimental, but those are the families that follow our guidelines and are not manipulating us or threatening us or getting in our way or walking all over us. But there's always someone who will do all of those things, and tact or compassion do not help. We as nurses are able to combine the "art and science" of nursing that we heard so much about in nursing school in order to provide individualized care; I think "family care" also has to be highly individualized, all visiting policies need breathing room, yet nurses must be empowered to stand up for safety, for what is best for the patient (their number one priority) and then what is best for the family (second priority). Sorry for being long-winded - there's just no simple answer to everything brought up in this thread!

First, I work in a busy (who isn't...) 30-bed med-surg-neuro ICU in a large metro area in the middle of scary neighborhood. We are open to visitors 20 hours a day - we close for an hour at a time during change of shift (07-08, 14-15, 19-20, and 23-00) which is quite often not at all well received by acquaintances/friends/sort-of family, but usually received okay by immediate family (except some who will never be happy - we all know who they are). We do make exceptions - comfort care/out-of-town visitors/pt just got there or got stabilized - but make it a point to inform people that it is an exception and that this will not be accepted in other circumstances. In my experience, there are plenty of people out there who ruin it for the whole population. I am very glad that we close when we do, and I am very comfortable asking families to leave when I am doing cares/assessing the family - and always go and get them when I am done if I have told them I would. In a perfect world, open visitation is a wonderful thing. But in REALITY, I do believe that if we are not able to stand up and give pts their privacy, do the care we need to without interruption, and play these situtaions by ear (as far as pt needs, family needs, and how appropriate families are acting), patient care is compromised. Just a few specific tidbits that came to mind... all three ICUs in my hospital had tried totally open visitations with no restrictions. Mine was the first to institute any restrictions, and the other two have followed suit as they found it to be too chaotic especially around change of shift time. After reading the article about pt satisfaction scores, I wonder how HIPAA fits in... this article says that people were dissatisfied with the information they got. But I have to be careful that I don't even tell the wrong person that the patient is even a patient in my hospital to protect my license and the patient's confidentiality. Interesting story recently - a patient was terminally ill and had a very dysfunctional family. Had a specific list of family members who could see him/have info. He died about midnight with all of those family members at bedside. Between 04-07 (and probably more on day shift, I don't know) we received at least 5 calls from "family" who were not on the list inquiring how his night went. When told they needed to talk to his immediate family, we repeatedly heard, "but I am family, how was his night?" These people would say they were dissatisfied with info - but at pt's request. Okay, so a few other problems I have with some (not all family members) - I have more than just a few times had family members turn off my patient's vent and monitor alarms "because that's what you did when you were in here and told us not to worry because he/she was coughing." And that is keeping your family member safe???? How will that stand up in court when you sue my hospital for allowing your family member to die and I don't have proof that my "negligence" had more to do with you touching things you shouldn't have? As far as codes go, we don't have a full policy as far as I know, but play it on a case-by-case basis. I have had three experiences of families being present - two of which were bad experiences, all three codes which ended in the pt dying. Screaming and yelling and falling down on the floor in hysterics are what I mean by bad experiences. The one good experience happened to be the patient's wife who was well-prepared that this could happen and immediately said that we needed to stop and let her husband go. Re: pets - we have an infection control policy about pets visiting and as long as they follow the policy, we do allow them - I have had one patient's pet visit her. It helps that we have glass doors and she happened to be in one of our negative airflow rooms so we had two sets of doors that helped us feel like her cat wouldn't get out if we needed to walk in. Her son brought her cat a few times - and it was always fine. Actually, the poor cat was scared of everything and hid in the corner the first time, really didn't disturb anything - but this patient was relatively stable, too. It's sad to me that the horrible family experiences are the ones that stick out in our minds. I wish I could say that I was always positive about family members - usually it's really not detrimental, but those are the families that follow our guidelines and are not manipulating us or threatening us or getting in our way or walking all over us. But there's always someone who will do all of those things, and tact or compassion do not help. We as nurses are able to combine the "art and science" of nursing that we heard so much about in nursing school in order to provide individualized care; I think "family care" also has to be highly individualized, all visiting policies need breathing room, yet nurses must be empowered to stand up for safety, for what is best for the patient (their number one priority) and then what is best for the family (second priority). Sorry for being long-winded - there's just no simple answer to everything brought up in this thread!

I just learned this one from another RN I work with... haven't gotten to try it much, though. There is a pressure point just below the jaw (right below the joint, in your neck, maybe one finger-width in front of the joint, where there is a little indentation). Press both sides of the neck at this point while deep breathing. It worked for me. Just be sure you don't press too hard/too long as I think it's right over the vertebral artery. I know the spot is hard to describe... hope it works!

I don't know that there is a good answer to the inappropriate admissions - I think they happen everywhere. I work in a 30-bed med-surg-neuro ICU, with two other ICUs available (CCU and CVICU) in the hospital, and although we don't have specific admission guidelines, a lot of our neuro patients automatically come to us after specific surgeries, ones that could have gone to the neuro floor. Luckily, some of that is beginning to change. And we have support from the director of our intensivists - if we get report on a patient that sounds like an inappropriate ICU admission, we usually are able to have someone (intensivist, house officer) assess the patient and kind of make the call. Often we are full enough that we have one admission bed, either saved for a code or neuro pt (we get a lot of outside hospital neuro admissions). Anyway, I wish there were good guidelines - but sometimes it's just politics or someone's gut feeling, whether it's right or not.

No matter where you are - med-surg, tele, ICU/CCU, ER, your first reaction in a code is the same... adrenaline rush and ABC's. Your hospital's code team will probably "take over" as soon as they get there for things like rhythm interp, meds, etc - the things that might freak you out the most. Here's the deal - the only way to get past that anxiety is to be involved in codes. I agree with what someone else said - ask if you can go to codes to observe. And taking ACLS wouldn't be a bad idea. Maybe before you do that, take an EKG interpretation class. Whatever you can do to learn, do it. But be reassured that in a code situation, you don't have to be the one who knows everything. There will be others who have had lots of ACLS practice.

A couple of thoughts for you.... First, was he agitated as an ongoing sort of thing? Or was that how he "expressed" his vasospasm? Not that that would change how you would treat his agitation by a whole lot, except that it would prove that you want to keep his BP up. Second, was he diuresing well enough? Though many neuro pts have issues with cerebral salt wasting and diurese all the fluid you give them no matter what you do, you do have to be careful that you are not fluid overloading them. What I am getting at is that fluid overload could have pushed him into A fib. Basically, what we always have to keep in mind is that what we are doing to treat our neuro pts, esp if they're having issues with vasospasm, puts a stress on their cardiovascular systems and it can be hard to find a happy medium. Our neuro interventional radiologists and neurosurgeons like our pts' BP up above 160 after their aneurysm is secured (coiled or clipped), so we often have them on plenty of IV fluid as well as pressors. But it definitely stresses the heart. About the Haldol, you are right that it can cause prolonged QT intervals. I honestly have only seen in once (though I am by far not the most experienced in this area), and it was really over a longer period of time where the pt had been getting Haldol on a regular basis. To be honest, my guess is that the stress on the heart was contributing to EKG changes more than the Haldol did, but you are right to question giving it. I don't know if any of that helps - I don't have all the answers but maybe that helps process it.

Good job with your first solo patient - I have to admit, we seldom give a patient with quite that many things going on to someone new off orientation on our unit. :) A quick couple of comments on Nipride - we use it very frequently especially as we are a med/surg/neuro ICU and our neuro patients tend to run high when they're at risk for bleeds. Anyway, like Begalli noted, nipride is very potent but has a short half-life, so you can always start slow but also remember that you can just shut it off and start at lower doses. About the cyanide toxicity... do you not have your nipride mixed with sodium thiosulfate? I thought it was a requirement. This is actually the antidote for cyanide toxicity. Our nipride gtts are always mixed with sodium thiosulfate and we run patients on HIGH doses of nipride at times (I have seen 5 mcg/kg/min and up) for long periods of time, and we do not ever have incidences of cyanide toxicity.

Okay, I'm not an ED nurse, so I don't have so many of these funny stories, but here's one that our ED was going to admit to our last ICU bed... until someone down there turned on their brain.... :) (My guess is that the doc was going to admit the kid but a good ED RN at least talked them out of an ICU bed for him.) Anyway, this "kid" - I don't know how old, probably 19 or 20, had been out drinking on Friday and Saturday nights, and Saturday had taken a bunch of Tylenol as well. Sunday his friend who he had been drinking with and who had also taken Tylenol ends up in the hospital with acute liver failure. So on Monday night, even though he felt fine, he and his mom decided that it was time to go to the ED to get checked out. So a full 48 hours after the fact, it was an emergency. His LFT's were normal, vitals rock solid stable - yet they were going to admit him to the ICU. We were already having to turf some other less stable patients to telemetry, because we didn't have beds or staff... so luckily I think they decided that they could send him home - not even admit him to med-surg to watch overnight.