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.

I don't know if this will offer you any comfort, but I work in a Cardiovascular ICU. We do heart transplants, and I have worked with many patients whose lives were saved by the selfless gift that your patient and his family gave. Just last week, a patient very well known to us, a lovely man in his late 40s, received a heart. He did amazingly well, and left the ICU post-op day three. He will be able to dance with his daughter at her wedding thanks to the generosity of a patient and family similar to the one you write about.

I love all of the comments about helping your co-workers out and I agree! If you've got the spare time and you know that your neighbor is in the weeds, step in and give them a hand. I will add, try to think ahead about what the patient and her/his nurse might need for the next shift. As a day-shifter, I might notice my patient's BP creeping slowly upward over the course of my shift. If the SBP has been in the high 130s for the last two hours, and the parameter is to keep it less than 140, I will call the NP or MD to discuss and get some PRNs ordered before I leave. That way, the RN that follows me doesn't have to call a grumpy surgeon at midnight. My night-shift colleagues do the same for me. If I come in and find out I've got to take a patient for an 0800 MRI, the transport monitor is already in the room, the extra-long MRI tubing has been attached to my lines, and extra bags of any infusions that may run low are hanging from my IV pole.

What was the patient's underlying rhythm (Sinus Brady, Slow A Fib, Junctional Escape)? What were the pacer settings that you tried? Did you turn the sensitivity numbers down to their minimum and still, the pacer was not sensing the patient's intrinsic rhythm? 1.Changing out the box, suggested above, is always a great idea. 2.You can also try changing out the cords--the ones that go from the epicardial wires to the pacer box. 3. Were the pacer wires appropriately attached to the pacer box? Meaning, were the atrial wires connected to the atrial slot in the pacer and the ventricular wires connected to the ventricular slot? 4. You can also try inserting an indifferent wire.

I dunno...I feel like a lot of people are piling it on BrandonLPN when he is just being upfront and brave enough to tell it like it is. My only experience in LTC was way back in clinicals, but I remember seeing that staffing there did not allow for residents to get an ideal level of attention/care. I work in an ICU, and even with a low patient load and tons of staff, it is still sometimes a struggle to gather the help necessary to move a patient. So I really sympathize with BrandonLPN's situation. To the posters saying that non-emergency meds can wait and patient cares should come first, I think that is just unrealistic. OP has 49 patients. If he interrupted his med pass every time a resident had a request, he would never, ever complete his med pass. Staffing ratios in many LTC facilities just don't allow for staff to drop everything to fulfill Pt requests. It's not that the staff is unfeeling, they just don't have the resources.

The only order I see a problem with is the NPO order. If he is a Hospice Pt, and he wants a drink of water or some ice chips, he should have that. You said that the patient had been miserable. Why not give him the medication he needs to not be miserable? Medications were ordered to be given even when he was asleep. Perhaps this was to make sure that there was a basal level of medication in his system at all times for comfort. We all know that bodies need sleep, and patients will sleep through pain, only to wake when their pain is out of control. Giving pain meds even while the patient is asleep can alleviate this, and provide them with more steady control. Hospice care can be very hard on nurses, and it's made so much more difficult when we see ourselves as quickening death. But you describe a situation where a man is dying, very soon, and there is nothing anyone can do prevent it. The intent of your interventions is not to quicken death, it is to give him and his family comfort and peace during this time. Rest easy.

I agree with Orca. This is a big, complicated change. It will take some time before it is all sorted out. Both people and businesses right now are confused and frightened by the change and are reacting and posturing. There may be some difficult times ahead as we all adjust. The BEST summation I have read of the ACA is in the following link. It is a clear, thorough, unbiased, and succinct (relatively speaking, it is a big bill) explanation of the ACA: CaspianX2 comments on ELI5: What exactly is Obamacare and what did it change? Read it, so that you can be more informed about what the bill does and does not do. For full disclosure, I support the ACA. I only wish it had included a Public Option as well. As it is, I think it is the most reasonable way to ensure health insurance coverage for the maximum number of citizens within our current for-profit health insurance system. A few weeks ago we had a young man (40s) admitted s/p CABG. He'd had stents a few years ago (bad genes!), but could no longer afford his meds. He is a laborer, and supports a large extended family. We, as a community, paid for that open-heart surgery. We could have paid for Plavix instead. I know a good deal when i see one.

$5 cafeteria gift card.

This is the best summation of how I feel about my profession that I have ever read. You really articulated it for me. OP, there are things that I love about nursing and moments every day that are rewarding. Working hard with a patient and taking them from being intubated and sedated at the start of shift to sitting in a chair and taking clear liquids at the end of shift. Trusting in your knowledge and your assessments, and sticking to your guns by having serious discussions with the MDs on your patient's case--seeing the plan of care altered for the better based on these discussions. Talking to a family who is really, really scared and explaining and normalizing the situation for them so that they understand what is going on. I leave work many days feeling both proud of how awesome I am, and incredibly privileged and lucky that I am allowed to work with people at such vulnerable points in their lives. Very heady. But there are also so, so, so many days that I leave work demoralized by the job. Edicts handed down every day from committees full of people who you have never heard of, and who have no idea what your job entails. Your organization pays big money for an "efficiency" consultation group to walk around with clipboards for the week to observe nursing staff, and when their results show that what is really needed is more staff, the entire expensive enterprise is abandoned. You bring up a real concern at a staff meeting ("We are starting to see so many bariatric patients, and we really want to be sure that we help them to be as active as possible, but we don't have the staffing.") You hear nothing for weeks. Six months later, a new double-charting initiative is announced, aimed at making sure bariatric patient activity is charted. I could go on and on, as I'm sure most posters here could. It's not nursing that gets you down. When you have been a Nurse on your shift, you are uplifted and flying high as a kite. It's the job that gets us down. I still haven't found a solution to that conflict.

Really, I think hours are going to vary based on the institution. On my Unit most of us generally work 2 eight-hour shifts and 2 twelve-hour shifts per week, for a total of 40 hours per week. Salary is very regional. I've found that Salary.com isn't very accurate. If you know a nurse in your area, ask her/him about reasonable starting wages.

All right, I'll bite. I've lurked on this site for a few years and this discussion was what finally prompted me to join. Here is my anecdotal story to illustrate why we need universal coverage: About 15 years ago, my mom sneezed, and afterward, her neck hurt. She spent a few months in pain, trying to correct whatever had happened with stretching before she finally went to her MD. Her MD told her she could try traction, or she could have back surgery. My mom, who was on a great health care plan, wanted nothing to do with surgery if there was another option available. Her MD prescribed a traction device which is basically a jaw strap which is attached to a bag. She fills the bag with water, slings it over a door, and sits in a chair with the jaw strap on. It worked perfectly. The traction relieved her pain and she was good to go. A few years later, my step-father died. My mom was insured through him, and stayed on his insurance through COBRA. A few months before her COBRA coverage ended, my mom started searching for personal insurance. She was denied by every insurance company which operates in her state because there is a note in her medical record which says she was offered an option of back surgery and she declined. No insurance company was willing to provide coverage for her on the off chance that she get a wild hair up her a** and decide to undergo the back surgery which she declined before. The upside of this story is that my mom is lucky enough to live in a state that has high-risk pool-coverage. She has health care insurance. She has health care insurance at $800 per month with a $7500 deductible. She pays $9600/year because her medical file mentions that 15 years ago back surgery was an option. So ends my anecdotal story on why we need universal coverage.