ausrnurse

Just to play devil's advocate for a moment, it's possible your preceptor was trying to check that you had followed up on something without you thinking you weren't being trusted - but obviously didn't do a good job. I will often quietly double check things with doctors that I know well and have a good relationship with. Not to try and embarrass somebody but to ensure that something has been followed up without making the new nurse feel stupid at the time. To use your example, if I discovered that a patient had a low potassium and the new nurse should definitely know and have acted on it by now, I might quietly say to one of the doctors, "hey, the K is 1.8, were you aware?" If they were, awesome job! If not, then that's a serious conversation I need to have with that nurse. New staff in the ICU I work at get checked up on all the time quietly in the background - we are just looking out for you and the patients in what can be an overwhelming environment with the benefit of experience and making plenty of mistakes ourselves, we don't mean to make you feel like you're not trusted! :)

I wouldn't mobilise a patient on dialysis back when I was a dialysis nurse, let alone an ICU patient with a a bunch of other things going on. I have no problem with sitting out in a chair though, although I know a lot of nurses I work with won't do it because they think it's dangerous in case of hypotension/cardiac arrest, however both of those things can be managed in a chair (our chairs are the same as used in a renal unit so they have a CPR function and a trendelenburg option). I'd prefer to do it with a SLED type therapy than a CVVHD however.

I think the OP needs to clarify the hospital policy in regards to this. I mentioned this earlier, but at my old job we had standing orders and could write and sign our own pathology forms. At my currently job this would be considered well outside my scope of practice and I would expect to get into very serious trouble for doing it. I don't see why the RN couldn't have chased up the doctor and asked them to sign the form, it sounds like they were only a couple of minutes away.

Very true. Different hospitals have different policies regarding RN's signing path forms. I was allowed to at my old job, if I did it at my current job it would have the same consequences as me ordering and signing for a medication on the med chart. If this is your hospitals policy, you need to report this nurse because as someone mentioned earlier, what else is this person happy to forge a signature on? You also need to CYA, I have heard of a nurse forging a doctors signature on a number of different occasions and when there was a patient incident, she got in first and blamed the junior staff member that had witnessed her doing it more than once but had not ever reported it. As jadelpn mentioned, in the future you need to say something at the time as well.

This is one of those things that just gets better with experience. First, I pull down everything that's not being used. For example, all our patients come back from theatre with noradrenaline and GTN running (why??). You're obviously only going to need one of these, so get rid of the other. They also inevitably have insulin running, diabetic or not (again, why??), get rid of this if you don't need it. Check your compatabilities. Inotropes always on their own lumen, and whatever your unit policy is for the rest. Untangle the CVP and art line, then move on to your pressure cables and monitoring. If they've been in theatre, no doubt your central line has somehow become looped six times around your ETT, so it does take a bit of time figuring it all out, and for safety reasons you need to.

No respiratory therapists and for safety reasons.

Hello, I am Australian but not in Melbourne. It seems like ICUs are very different here, but I think for the better. 1:1 ratios for ventilated patients and closed ICUs with intensive care specialists. :)

What the! 45 minutes late! Honestly, I think anything more than 5-10 minutes is pushing it and I would have been calling to find out where she was. My workplace starts calling after about 5 minutes past your start time. I once worked on another ward relieving for a shift though and the nurse I was paired with was half an hour late and nobody said a thing although she apparently did it all the time!

These targets are absolute nonsense. Patients get transferred before even being worked up or stabilised and you end up with a hot mess on your hands, by the way you only have one cannula for your critically ill patient and they haven't been through the scanner yet*. I could go on and on about my opinion of these ED transfer targets, but there would be too many expletives for AN. Patients should be moved from ED in a timely fashion - but not before they've done their job. It's totally overridden clinical judgement and all you get is a shrug and "it's been 2 hours." *not to mention putting these people in an elevator and transferring beds is a disaster waiting to happen!!!

Like everyone has already said, I would remember to double check the post op orders and then try not to worry about it anymore. The doctor should have actually double checked that he'd prescribed the meds he wanted given. This is just one of those things you don't get taught at university - surgeons will write post op instructions, usually on a form that gets left in theatre, never to be seen again. Then they will come down to the ward and kick up a stink about their instructions, still sitting in the printer in OT, not being followed - if they bothered to write any at all, sometimes they expect you to just be straight up psychic Now you know to always look for those instructions and to follow up on anything that's missing :)

I don't mind so much if it's the original packaging on the way to draw it up (eg., a vial of antibiotic powder before reconstitution). I think carrying IV medications that have been reconstituted is an infection control risk and you are risking leakage or contamination as mentioned above. I would be seriously questioning a persons common sense if they told me they walked around with narcotics in their pocket. That is completely about covering your own backside and I would not want to be the nurse who was known for carrying a drawn up syringe of IV fentanyl in my pocket if it started going missing.

Wow, I can't imagine not being allowed to bolus propofol or titrate meds! We can bolus as much as we need to taking into account the pts blood pressure, letting the MO know if the pt is requiring large amounts of boluses to remain settled. Same with fentanyl and midazolam. We don't really use ketamine often and although I think you can bolus it, I prefer not to unless asked to by a doctor. I work in a referral centre however and I believe that in smaller units that only hold ventilated pts until they can be transferred to us they don't and is mainly because of a lack of experience with the medications.

I see you've never had a patient go into asystole from precedex There is a small group of patients it does work well on - typically post-ops with anaesthetics still on board and imminent extubation and the occasional tubed patient withdrawing from alcohol. That's about it. I've only had maybe one or two good experiences with the stuff, some of our intensivists love it in the MICU but the cardiovascular side effects are SCARY. I've seen blood pressures swing up and down from 50 systolic to over 250, patients brady down to nothing out of the blue. After seeing someone have a cardiac arrest that was directly linked to the precedex, I have really hated it and that person was on a minimal dose of the drug and was only tubed for psych reasons (nothing medical going on). I can barely bring myself to titrate up to an effective dose these days. You guys sound really lucky in your ICU! :)

Now you will remember for next time :) We have similar pumps that should also clamp after the cartridge has been inserted in the machine but I usually try to clamp the line with the roller clamp as well - just in case. I doubt a few drops of pantoprazole had any adverse effect on this pt, I think the hypotension probably had another cause.

I read somewhere that doctors always think patients are oversedated and nurses always think they are undersedated. Personally, I've never seen a nurse deliberately oversedate a patient, and if they did someone would say something to them. Occasionally a new ICU might, usually out of fear/anxiety more than anything - but I think it's better for a new nurse to give an extra bolus of propofol and ask for help than ask for help after the ETT is lying on the floor. Much easier to fix the sedation. Totally agree with you on the precedex, I HATE the stuff.

I'm not sure how supportive the medical team is in your particular unit, and it might be easier for me as I work in a closed ICU with 24/7 intensivist cover, but if one of the more junior doctors tries this nonsense with me I start with "how would you like it if that was you?" followed by "the patient is undersedated and they are going to self-extubate." I normally refuse restraints on a patient for the sole purpose of keeping someone undersedated if that is brought up - obviously depending on the patients mental status. If they continue to refuse appropriate sedation I go over their head - I will bring in senior nursing and medical staff if necessary. I am not prepared to restrain (assault!)* someone because a doctor isn't confident in their ability to appropriately assess a patient for extubation and if necessary, reintubate, which is really what this sort of thing is all about. Self extubations always require an incident report in my unit. *obviously I'm not talking about patients that are confused/take days to wake/etc. I'm talking about a normal extubation where some people seem to think that even if the patient is totally appropriate, the sedation needs to be left off for a certain period of time before pulling the tube.

We turn off our sedation every day to assess the patient for extubation and give them a "sedation vacation" (leading to shorter length of intubation). When they are ready we extubate. If they are not ready but comfortable, we leave the sedation off until they are ready. If they are not ready and uncomfortable we resedate (possibly changing the sedative) and try again later. It sounds like your hospital needs to rethink your sedation protocols. Imagine the psychological effect of being awake, tied to a bed, unable to communicate until someone takes the tube out. I would consider it assault, they need to either resedate or extubate. We almost never use restraints.

I can't believe how much this thread has been derailed by the use of the word "snitch". Are you kidding me? Dobbing, tattling, whatever you want to call it, it's childish and it is my number one pet peeve. Nobody here is talking about situations that clearly need to be brought to the managements attention (patient safety, very hostile, unprofessional behaviour). This is about situations that should have been resolved at the time they occurred. I work in a unit where it is totally acceptable and encouraged to run to the managers about totally ridiculous things like rooms not being restocked with exactly 5x 10ml syringes and 10x vials of normal saline, being 30 seconds late returning from a break, daring to be friendly enough to speak to your colleagues about anything non-work related, and these people get a pat on the back for acting like 6 year olds! How hard is it to say to somebody nicely "would you mind remembering to restock your room before handover?" or "I prefer not to talk about my home life at work, thanks for asking though."

Propofol for short term sedation, midazolam for long term sedation. I HATE dexmedetomidine. 99% of the time the way it is prescribed is not the way the drug is meant to be used (eg., is written up instead of propofol for a neuro patient trying to rip every tube and line out with no plans for extubation), and I find the bradycardia it causes even at tiny doses to be very disturbing - you can't even have it running at an effective dose due to the side effects. Hate it!!

Everybody fills in what they would like to work on the request roster. Nobody is allowed to have both holidays off - you either get Christmas or New Years - or you can work both if you want to. There are plenty of people who are happy to work for the public holiday pay that it's not often that people do not get what they want.

Australia has a similar rule, but we don't say is must be a lunch break, it's just a "break", so usually morning tea, which we start around 8.30, then start lunches around 12. We've never had an issue.

I don't think I've ever actually said that we are short staffed, but I will often say that it's very busy today when people ask me why I'm running around like a headless chicken. People are more understanding if you admit that you're busy. I don't know why we shouldn't be able to say we're short staffed - especially in places with a public health system (Australia, Canada, UK). The government that is cutting the funding for staffing should be held accountable by the patients and the staff!

We do our own in ICU, but the phlebotomists do the 0600 bloods in the med/surg wards, then head down to the clinic and do the outpatient bloods. It would be awful for the nurses in the wards to have to draw blood on 6-10 patients every morning on top of everything else.

It's always the same group of people who never have time for a break. They're the same people who expect a spoon fed handover and are unhappy to have any jobs that need to be completed on their shift. It's poor time management. I ask them if they want a break once or twice and then I send someone else. The entire unit doesn't revolve around them. This is talking about a normal, steady shift at work. I've worked shifts where it was so busy and the acuity so high not a single one of us got a break - this is not the same thing. I've seen people looking after one single walking, talking patient waiting for transfer to the warm and they try to tell me they are too busy for a break. Busy doing what?

Try not to let it get to you. It's pretty old fashioned that you are even doing cardiac outputs on a patient In two years at my ICU, I've never seen a Swann-Ganz. I think they talked about one once as a joke. Seriously though, it's part of working in a new area. It's an area you feel like you can't make a mistake in - but everybody does. There are a lot of big personalities and plenty of people that take pride in making new people feel stupid but honestly, one day you will get a sick person that you can manage on your own and you will be able to let it roll off your back.