OnceMorewithFeeling

We actually recently went in the opposite direction in my unit. It used to be a free-for-all. We are now a locked Unit with an official visitor policy--three visitors at a time, visits discouraged/restricted after 2100. For critical or dying patients, we have discretion to make exceptions, and we always do. It has made a world of difference in helping our patients recover more quickly. The simple conceit that visitors must gain approval to enter has cut down on the extraneous well-wishers that don't do much but tire our patients out enough that they can't do PT/OT. I have also felt a real change in visitors understanding and respecting the important work we do. Sometimes they buzz to visit and are told they need to wait a few minutes, that the nurse is working with the patient. The RNs on my unit don't abuse the system--we always let visitors back as soon as is possible and let them stay as long as it is best for the patient. As a bonus, since we went to a locked unit, we haven't had any visitors bring heroin or oxy to a patient! Overall, the Locked-Unit with more restrictive visiting hours is really working for our unit.

I think that we need to remember that the term discharge” does not mean discharged back to home, fully functioning, baking muffins for the grandkids.” Discharged simply means discharged from the hospital, and it often also means that the patient was trached, pegged, PICC'd, and sent to LTAC or a Skilled Nursing facility where they will live a few more weeks or months. My problem with the mindset of coding everyone just for that small chance that they make it” is how we define make it.” Once a patient has been coded and has achieved ROSC, I find it becomes incredibly hard for the family to re-center and make rational decisions based on the patient's previously known wishes/best interest. They are of the mind that Grandma made it through the code, (she is a fighter!”), so she must want to, and have the capability of, fighting through all that comes after coding. Then comes an escalating chain of decisions to intervene and the family feels like they can't turn back because they and Grandma have invested so much, even though Grandma is fed through a tube, can't talk to or recognize anyone, breathes through a hole in her throat…etc. Too many times, we resuscitate people only to give them a miserable, suffering few weeks or months before they ultimately die.

100% this. You must document your phone orders. If you work in a facility where the phone orders you take later get disputed, this will protect you.

I was a new grad in the ICU. How did it go? Not so good at first. Orientation and the initial year after orientation was pretty terrible. For both me and my patients, honestly. I should not have started in my ICU--I had zero health care experience, not even as a CNA. I was also horribly nervous and timid and unsure of myself. Looking back over my first few months after orientation, I can't believe that I didn't kill anyone. I cried every day. I threw up from stress many times. It was not a good experience. If I had it to do over again, I would have started on a med-surg floor and worked my way up. That was my experience (pretty timid person, scary-sick ICU patients, no healthcare experience, but Unit is super-short-staffed, so you got hired!), your experience might be different. Having said all that, I did make it. I'm still there, eight years later. We've had a new Manager for the last five years, and she is wonderful. I am a resource and expert to many other staff members. I am the go-to preceptor. It's pretty great, and while I might grumble sometimes about having to wake up early to go to work, I love my job. I am exceptionally good at my job, and that feels amazing, every day. Do you wish you had prior experience in another unit before the ICU? I absolutely, 100% wish I had. I would have been so much better prepared with a year or two of med-surg under my belt. I am not exaggerating about how bad that first year after orientation was. Having said that, I have precepted quite a few new grads. Nearly all of them have been equipped, inquisitive, delightful, knowledgeable, valuable members of our staff. I have been so impressed by their drive to learn and how well and quickly they have adapted to our Unit. I don't know what they have that I didn't, but they are way better than I was. Did you feel well-supported as a new grad in the ICU? Not at all. Our unit now has a program for new hires for the first year. They meet every few weeks to work on projects?

I wonder, is your perfectionism internally or externally motivated? Did you feel bad because you thought you should and could do better by your patients, or because your colleagues pursed their lips at a bath you couldn't get done d/t an unexpectedly busy shift? Or because you didn't get that "one-super-super-Charge RN -Report" filled-out exactly and on-time. Based on your comment "the fear of being judged," I think that a lot of your perfectionism is externally-motivated. I think that nearly all of us start our careers with external motivation as our primary driver. We want to please our preceptors, our patients, our managers...etc. I think that nurses in unsupportive environments stay in this mode. In supportive environments, and with some time and experience, nurses transition into a more internally-motivated mode. They do what they know is the right thing to do, even if others might not agree, or have different ideas. They are open to discussing their rationales, and to hearing and incorporating the rationales of others. They don't sweat the small stuff, but they do respect their colleagues and the oncoming shift. My advice would be to find a healthy place to work. One that supports nurses and one that encourages a respectful environment among colleagues.

I have been closely watching both the House and Senate's efforts to repeal the ACA. As nurses, we are on the frontline of our nation's health care delivery system, and it seems to me that we have a lot to add to this issue. Questions: 1. How would you fix the ACA? 2. What is the perfect healthcare system for the U.S?

So, when you don't get an uninterrupted break are you paid for that time? 30 minutes unpaid three times per week = 1.5 hours. 1.5 hours times 52 weeks per year = 78 unpaid hours

I have been an RN in an ICU for over six years. I have never, once, not felt "behind." I am always anticipating. Once the "expected" anticipations are resolved, my mind wanders. Even on the rare days that I am 100% caught up on charting, and my patients are exhausted from all the ambulation I've enforced, and I've reviewed their entire charts and can't find a test or lab that we might need, I still feel behind. What if there is a test/lab they need that I haven't though of? What if something comes up? (a lab, or a test, or a road trip...). Partly the nature of the beast, and partly my personality!

Seriously though, I get real twitchy about the whole "lunch" break thing and what it is. If you get a free, totally uninterrupted thirty minute break from your duties, that is an unpaid lunch break. You are able to do whatever you wish during that time: Tai Chi in the parking lot, driving to and from Walgreens to fill a prescription, stuffing your mouth in the cafeteria--doesn't matter what you want to do, this is _your_ time. If you take your zone phone with you and it rings and you answer it, and the call is related to your patient, you did not get a thirty minute lunch break. You get paid for the whole thirty minutes. If your patients are unstable and you run back for ten minutes ten times to nibble during your shift, that is paid time. If you are working through your lunch break and you are not getting paid for that, you are contributing your time to your employer. Here is the math for what you are contributing: 36 hours per week, 1.5 hours per week unpaid lunch equals 78 hours for one year. You are contributing over an extra two weeks per year to your employer by taking unpaid lunch breaks. You could have gone on a fabulous vacation with this time. Instead, you are at work, unpaid. You are essentially gifting your employer two weeks of your time every year. On a unit that employs 30 RNs, that 1.5 hours each day for one year becomes 2,340 hours. Gosh, it's almost as though the facility could afford to hire a break RN, right? Wonder why they don't? For all of those RNs pressured by their managers to work off the clock either during their "lunch breaks" or after their shift has ended, your State Department of Labor in your state is a great no-cost resource. Most DOLs will take anonymous complaints.

Breakfast break? Is this a thing? Where do nurses get this?

I did not find school hard, but I found it very, very time-consuming. Keep in mind, I did not have a husband and kids like you do, so it it will be different for you--it might be hard, depending on your other obligations. I did evolve into a good nurse, but it wasn't because of school. It was because the orientation I received on my unit, and sticking it out for the year or so after orientation when I felt so much that I had no idea what I was doing. My advice is: 1. Get a CNA job while in school. I did not do this, much to my detriment. I would have been light years ahead during my orientation if I had. 2. Listen to and absorb from every knowledgeable nurse that you can. 3. At clinicals, do not try to judge or evaluate the RNs you are with. They are doing their job to the utmost of their abilities, and they have constraints upon them that you cannot yet imagine. (Unless they are abusing patients. Then, report their a**es.) 4. Use that Planner! Schedule your life! Classes, daily study time, test prep study time, writing paper time, meeting with group project people...etc. If you can plan it, you can do it!

benmca13, I hope you read all of the replies to your post and learned something new. I just wanted to the highlight one portion of your post that I thought was the most important, and the one we should all remember: "She was A/O x3 on days but when I came on she could hardly answer any questions. Got her on bipap overnight." This is the biggest mistake we, as RNs, can make--ignoring neuro/mental status changes

No, this is not okay behavior. Assignments should be based on what is best for the patient--who has had this patient before and therefore knows her/him, who has the skills/knowledge this patient needs...etc. On occasion, we will have a patient in our unit for several weeks with the same nurses caring for her/him. If it is a challenging patient/family, after six or so shifts, an RN will ask for a break, and that is absolutely accepted on our unit. On occasion, we have had male patients who get belligerent and abusive when assigned female caregivers, and so we staff only male caregivers for that patient. That's it, as far as staff accommodations. I am worried by the other information in your post--you are a pretty new nurse and you are taking charge in a critical care unit. That is the reddest of flags that this is a poorly managed unit—they cannot keep enough senior staff or will not offer senior staff the incentive to accept charge position. Further evidence is provided by the fact that RNs on the unit feel free to dictate assignments based on whether or not they can sit by their bestest friends. And they feel free to pressure you because you are new. I'm sorry that you find yourself in this situation. Charge nurses, especially in critical care units, need to be able to hear and weigh the needs of both the patients and staff, and to differentiate between needs and wants. They need to make tough and often unpopular decisions. Does your manager have your back on your assignment decisions? Is she or he present on the floor each day to help you work through difficult decisions? Is she or he aware of repeat assignment demanders,” and does she or he have a plan to curb the behavior? If not, I suspect that you work in a poorly managed unit, and these problems will continue.

You did nothing wrong. You had an incredibly busy day by your account, and were still thoroughly attending to this patient. Even after the fact, you can account for his vitals, his gtts, his mentation...etc throughout the day. You did all you could for him. I do agree with nurs1ing about your Unit's protocols for DC'ing chest tubes. Our patients need to be out of bed at least one time (and usually, 2-3 times) before we will DC chest tubes. Patients will retain a lot of fluid in the pericardium and pleural spaces that won't drain until they get out of bed. In addition, slow leaks can be identified by leaving the chest tubes in a bit longer. Perhaps your patient had a slow leak and developed tamponade after the chest tubes were pulled? As far as the "undiagnosed thoracic aortic aneurysm," I would be very concerned if your CV surgeons are operating on folks with undiagnosed or identified aneurysms. It's pretty important to know, before a CABG or other open-heart procedure, if a patient has an aortic aneurysm.

Based on the information you have provided, I do not think a fentanyl overdose is the culprit here. But, I am concerned about the management of this patient.