nursingjudgment

I currently work full-time in a level-1 trauma ICU and I really enjoy it there. I've been planning on going back to school, but in an effort to earn a little extra money and to see what else is out there, I signed up with an agency and (through them) I recently started working in the CCU of a very small hospital. Now, I'm happy with my agency, but I really DO NOT like the hospital itself. I'm actually surprised by how vehemently I dislike it (I am someone who likes most jobs), but I find myself actively dreading every shift. In short, I don't want to work there. However, I just started and so I have some concerns: a) Will my agency be upset if I walk-away from the first hospital they set me up with? I like my agency -- I just really don't like this hospital. b) Will it look bad on my resume for grad school [i'm applying to a very competitive program] if I have a very short ( c) I've heard that one can just 'stop signing up' for shift and then I will be auto-terminated for my position there, but I'm not sure how it works with an agency. Any insight would be great! Just to clarify: there is no bullying or anything that makes me dislike the hospital so much -- everyone is actually very nice there. It just isn't a good fit for me. Part of me thinks I should stay and try to give it more of a chance, but I'm genuinely miserable there.

I don't know if my input is helpful, but I personally think that doing nursing before going through medical school is a great idea. Why? Because I did it.. or sort of did. Ever since I was a kid, I said I was going to be a doctor, so naturally I was pre-med in college. However, I began to have doubts by my senior year (I met my then-serious-boyfriend, now husband and began to wonder what I wanted the next 10 years to look like; I worried about debt; I worried about matching... etc.). So I took a year off after graduating, and during that time began to consider nursing. Choosing between the two of them was terrible, and I dramatically cried-on-my-bedroom-floor when I eventually chose nursing. The reality was, medical school at that time was too expensive for me, and I was not prepared to commit myself to such an uncertain life-plan. The matching-system in medical school was really terrifying to me; there were specific types of medicine that I was interested in, and I wasn't kidding myself about how hard it would be to match with the things I wanted most, as they were very competitive specialties. I had always been at the top of my classes, but realistically that would also be true for many, many other amazingly bright medical students. Nursing, meanwhile, is delightful in that switching from one specialty to another is very easy; additionally, the path to nursing was less expensive and took less out of my personal life. For all of these reasons, I chose nursing. But I was terrified that I was selling-out a dream that I had had since I was a child, and I promised myself that if I wasn't happy, I would go to medical school. Today, I work in a SICU and I am grateful EVERY SINGLE DAY that I didn't go to medical school. I have never regretted it since the first few months of my nursing career in the ICU. Don't get me wrong: I love science. I love diagnosis. I love making decisions. But you know what? I do all of those things as a SICU nurse; additionally, I am much more aware about the actual condition of my patient than the doctors because I am there for 12 hours a day and know what every part of my patient's body looks like (sometimes that's a bad thing! haha). Also, I get to spend time doing small things that, before I became a nurse, I discounted as not that important to me but today I wouldn't trade for the world. I think that other nurses on this forum will agree with me that being the one to calm a screaming patient, to cry with loved-ones, to use a warm towel to wipe the cracking lips of an intubated patient, to DO the chest compressions, to say to a patient, "I know it hurts. You can hold my hand..." -those moments are so much more precious than you can know until you have experienced them. I love being hands-on, and the reality is that doctors are rarely hands-on. They write the orders, they review the CXRs, they are definitely incredibly essential and I wouldn't want to be in an ICU without a good attending and team -- but today, I can heartily say I wouldn't want to be one. In short, I definitely encourage being a nurse first to make sure that being a doctor is what you really want. Definitely being a doctor is more prestigious; you will make more money, and you will come out of school with a much deeper knowledge-base (as someone who loves school, losing that knowledge-base was painful for me). But the truth is that a lot of what doctors experience is tedium (writing notes, writing basic orders, ROUNDS [ugh... rounds]), and I (like other nurses on here) have personally witnessed how terrible it is to be a resident -- 24-hour shifts, unrealistic expectations and work-loads, critical attending and ACPs, condescending nursing-staff... I always try to make friends with the residents on my unit because I often think I could have been one, and I truly think that it is one of the hardest things that a person can go through. Think about what it is that appeals to you about being a doctor. Is it making the decisions? Is it the prestige (it's okay if it is; that's totally understandable - nursing is not prestigious and that can definitely make it seem like it is less rewarding than I personally think it is)? Is it the knowledge-base? Also, don't discount what people say about the joys of being at the bedside for 12 hours: when I used to read these forums before making my decision, I thought "Eh, I'm not a real people person, so really getting to know my patients isn't a big deal to me. All I care about is science-based medicine." Today, that is the most precious part of my job -- something I would never have expected. If you like being in the ED, maybe you would enjoy being a nurse in a level-one trauma bay?

I'm so sorry if I made it sound like I think the people I'm describing are stupid. I actually heartily agree - most of the time, I think they are just so involved in their own (often heavy) stresses that it is almost impossible for them to process another viewpoint. I also totally agree with your ADLs suggestion! Having a family member who wants to do basic ROM exercises, mouth care, or even (as you said) being a cheer squad -- oh my gosh, so wonderful for the nurse, the patient, and the family. Unfortunately, I think that in some cases (e.g. the wife who disconnected my chest tube intentionally), family members feel like they can do more than they actually safely should. Edit: just to clarify (I think this may have been what led to your comment), it was another poster who made the comment regarding stupidity. And I don't think that poster was calling someone stupid either. I think she was saying that she doubted the family-member was actually stupid, but instead perhaps intentionally harming the patient.

The funny thing is, I don't think she did want to! This wife CARED. She was ALWAYS there, and was extremely involved. As my husband says, I think a lot of these stories illustrate how crazy people can be in times of extreme stress. This particular lady (the chest-tube one) told each and every one of us how she used to be a nurse. It turns how she had been a lactation consultant -- definitely an important job, but not one that prepares you to make decisions in a level 1 trauma center iCU. I think she knew just enough about healthcare to know how often mistakes are made, which made her think that we were constantly harming her husband when we weren't. For example, he was on a lasix drip at 2mg/hr. She was very agitated about this, and kept talking to her adult children about how dangerous and strong lasix is, and what a high dose that is. Meanwhile the guy had a lumbar drain, and she clearly took it as a sign of dangerous ignorance on my part when I said that a patient can't be sent to a med-surge floor with a lumbar drain in place. Just to add to this story: my first day with her, I walk up to find her flipping through her husband's chart and I overhear her say to her son that she wants to take a picture of part of it to study later. I obviously explain just why this is completely illegal, and she was very offended and said, "We used to let people do it all the time!" When I continued to explain that she would need to formally request access through medical records before having access to her husband's chart, she says "Well, I guess I will have to get a doctor's order saying that I am allowed to look!" Okkayy, lady. Just let me know when you find a doctor willing to write that order.

I never cease to be amazed by how many family members want to give vented patients water/make them talk/pull out breathing tubes because they are 'uncomfortable,' ,' etc.. But our hospital is very 'family-friendly' so we essentially never ask people to leave. Actually, a few months ago, we had a wife who was genuinely dangerous to patient care. When I cared for the patient, she disconnected my chest tube from wall suction (intentionally). Other nurses reported that she did insane things like turning off running IV pumps, removing restraints (the patient of course pulled something important), and changing the inner cannula of a trach WHILE THE PATIENT WAS VENT-DEPENDENT! Although she continuously did these things which were endangering the patient and completely inappropriate, our supervisors made the patient a 1:1 (for close monitoring of the wife) instead of kicking her out. It was really serious -- like, if the nurse caring for the patient went on break, another one of us would have to sit in the room just so we could watch the wife.

I have a few. Ah man, there are some crazy people. I feel like I don't remember the best ones. I work in an ICU. 1) From the patient about his visitor: "My girlfriend fell and hurt her wrist a few days ago. Do you think you could put a splint on it and give her some aspirin?" Ah man, this guy was miffed when I explained the legal issues with treating non-patients. 2) Visitor (she was probably around 20) comes out of patient's room sniffing her pits, dressed to the freaking Ts. "Do you have any deodorant?" she asks me. Obviously we do, but I wasn't about to give out patient supplies to her, so I said I'm sorry, no. "Well, maybe you could go to another unit and get me some?" she says. Again -- so miffed when I explained that we aren't allowed to give out patient supplies to non-patients. (To be fair: if you are really nice and have been there at your loved one's bedside for days, I will go above and beyond for you. No problem. Actually it's my pleasure. But if you are dressed like you were out clubbing, just got here, and then ask me to go to another unit for YOU? No freaking way, man.) 3) "RUB MY FEET! RUB MY FEET! RUB MY FEET!" -- literally being screamed, for hours. You could hear it across the whole unit. Granted, this was one of those AAOx4 patients that you kinda feel like might break with reality at any time (something intangible didn't feel quite right with her although she was perfectly oriented), so I kind of forgave her, but still... the screaming. 4) Patient's estranged wife REALLY wants her ex-hubby (on multiple pressors, acutely unstable, vented and sedated) to be given water to drink and a bed bath immediately. He had already had a bath that day, but I wasn't opposed to the bath, I just wanted to get him his MRI trip on norepi first, and all that good stuff, so I very nicely explained to her that I would give him a second bath as soon as I had time. But no, he needed a bath now because skin was dry. I brought lotion for her. She looks at me and says, "What's in this lotion? We don't use just ANY lotion." Okayyy. I tell her that I am not sure what is in the lotion. I made some sort of a joke about the hospital certainly not shelling out for Bath and Body Works. I tell her she is welcome to bring in another lotion if she would like. Well, she makes a phone call and within 30 minutes someone has shown up with a strongly scented oil which she proceeds to rub all over him. There was oil all over my beautiful clean sheets and his central line dressing; I shed tears in my head, and the bath did go up slightly on my priorities list. I go help someone else with something on the unit, and while doing it look up at our unit monitors to see that my patient's BP has acutely dropped. I also hear vent alarms that could wake the dead. I run into my patient's room (RT right behind me) to find that the wife is trying to give the guy water. I ask her to stop (I had already explained why he couldn't have any water while vented)and quickly go up on my pressors. RT is trying to step past the lady to get to the vent, but she is in the way. She doesn't stop, so I ask her again with more authoritas. SHe looks at me angrily and says, "He's THIRSTY." "I understand, but he is very unstable and we need to calm him before we address that. The water can make him choke,and his vital signs are already in a dangerous place," (I said something along these lines). She ignores me and keeps giving him water, so I really pull out the mom-voice, and I say, "MA'AM, I NEED YOU TO STEP OUT OF THE ROOM RIGHT NOW." You had better believe I was pissed.My voice works, and she huffily puts down the water and demands to speak with me. I get my patient calmed and meet her outside the room, where she proceeds to literally yell at me about how, "She knows how to calm her husband better than I do!" and "She is going to school for this and knows what is dangerous for any patient, but especially her husband!" and (my personal favorite line from the whole bizarre encounter): "I have seen my husband's private parts many more times than you have!" (I think that last one was related to me asking her to step out while I changed his Foley; I do this in all situations for patients who can't ask for privacy, but ESPECIALLY in situations where the couple is separated. How do I know the guy wants her in the room for that??). In the end, a nursing supervisor had to come up and talk to her about patient safety in acute situations. She told the nursing supervisor that I was incompetent because "He hadn't had a bath all day!" but luckily the NS thought she was crazy. The wife did demand all male nurses after that though. I am pretty sure that was personal, but you had better believe I didn't shed any tears over being taken off that patient's care.

Do you feel excited by your job as a CRNA? I know you said you like it (and in general, the CRNAs that I know love their jobs), but I absolutely love the adrenaline that I get from intense situations as a SICU nurse, and I wonder if long days in the OR might not be for me. Also, do you get holidays off? Do you know CRNAs who work no nights, etc? Thank you so much for taking the time to answer our questions!

I can think of twonurses off the top of my head that I know were hospitalized for mental illness of one sort or another before they became nurses. They are both nurses now. If I know two, as a baby nurse, then there are lots. FYI, they are both great nurses and I would put myself in their care before I would put myself in the care of a lot of nurses who I don't know that about. All this to say: your past is what you make of it. It sounds like you are trying to make something good of it, so good on you. If you (and a licensed professional counselor/psychiatrist) believe you to be capable of nursing, then I wouldn't emphasize it in interviews. I would, however, make sure that I had a licensed professional who I trusted that I could work with during nursing school because it is a whole new level of stress.

1) I learned how to appropriately set the sensitivity and pacing threshold on my patient's external pacemaker. (I had learned how to do this before, but never actually done it on my own patient). 2) I learned that Guillain-Barre syndrome has a risk for bradycardia and cardiac arrest 12-14 days out. Watch for that! 3) I pulled my first PA cath! I also, in passing, feel pretty confident that I can recognize a good PA cath waveform now after being so concerned that the one my patient had was in the RV. 4) I learned: if your patient takes Haldol at home, he DEFINITELY needs it when he is in the SICU.

Thanks for the response! I was still a little confused so I went and looked at some journal articles, and it looks like tachycardia is usually caused by autonomic nervous system dysfunction, while bradycardia can be caused by 1)over activity of the vagus nerve with corresponding ANS dysfunction or 2) autonomic nervous system dysfunction. I think probably what was happening to my patient is what is described here: "Episodes of sinus arrest can happen during endotracheal suctioning in patients on ventilators, but can also happen spontaneously (as in our patient). It results from a malfunction of afferent baroreceptor reflex. Ropper et al [9] postulated that afferent baroreflex failure causes labile blood pressure and release of sympathetic efferents leading to catecholamine excess. This, in turn, sensitizes left ventricular stretch receptors and other nociceptors causing a compensatory reflex bradycardia. Manifestations of both sympathetic and parasympathetic excess may be seen in the same patient." (Journal of Medical Case Reports | Full text | Guillain Barre Syndrome with Asystole Requiring Permanent Pacemaker: A Case Report). I hope he was alright overnight! The bradycardia was a new issue, and we don't see a lot of GBS on our floor.

Hey everyone, So I had a patient with Guillain-barre this week, and I have a few questions. First of all, it seems that this gentleman was not a typical case as he did not present with ascending paralysis. However, he did eventually go into ARF and so he was intubated and brought to the ICU for a run of IVIG. Eventually he was trached and pegged, despite an episode of pneumonia. So here's my question: while I had him, he did not have a gag reflex. He also tended to run tachycardic (around the 120s). I mentally attributed this to loss of his vagus nerve and moved on with what were some very busy ICU days. But now that I'm at home, I'm wondering -- when you have GBS, do you lose some cranial nerves and not others? He didn't have full facial paralysis (although he did have notable weakness). Is there an 'ascension of paralysis' of the cranial nerves as well, up from the medulla to the midbrain? Also, as I was leaving yesterday, he began to go bradycardic. Again, I assume he was hypertensive and tachycardic because his vagus nerve could not counteract his SNS responding to the natural fear/stress of being trached and pegged in an ICU. But what would be the reason for his bradycardia?

I have a notebook too! It's the best. I actually have two -- one for drugs and one for miscellaneous information that I want to remember. Also, I didn't realize 'mid-level' was derogatory. I won't use it anymore!

icuRNmaggie, thank you so much for that advice. It is really heartening to have someone tell me that it sounds like I am where I should be -- it's so hard to tell. Your suggestion about clarifying the plan with the care team is also really helpful; it seems obvious now, but that is a great way of getting from them exactly what I need in order to plan the rest of my day. I haven't been doing that, but I will certainly start. And I will try to take "I'm sorry," out of my vocabulary (or at least to lessen its use)! I've been told to do that before, but somehow it seems to always slip back in. Thanks for the reminder.

Letterwritingman, I agree that I think horror-stories have something to do with it. I worry about everything: am I charting enough? Am I charting appropriately? Did I chart in a way that protected me? Am I meeting the standard of care? In school, I memorized every detail of so many things because we were constantly told the terrible dangers of not doing each thing a very specific way. On the floor, I see that things are rarely done the way I was taught (and I see that no one I work with actually remembers EVERYTHING that they learned), but I still feel as though I should remember everything and do everything correctly, even when it's impossible. Because every worst-case scenario I learned in school seems just a well-meaning error away. I have become so focused on the need to know everything (or else I am an 'incompetent' nurse) that I feel like my worry paralyzes me so that it's hard to use even the knowledge I do have.

Hey everyone, I am a new grad who started in the ICU in February. I have been off orientation for about two weeks, and it's been tough. I felt relatively confident in the weeks leading up to coming off orientation (and my managers gave me great feedback) but I feel different being on my own. I feel worried that I will hurt my patients, so I double-check and ask the more experienced nurses about everything (even things that they probably think I should already know, like how to mix Levophed or for tips on how to unclog an NG tube). I worry that this makes me looks less competent, but obviously I want to be safe so I keep asking. My real problem, though, is that when I do make mistakes (and obviously I have been making them), it's hard to deal with some people. Now, to be clear, the nurses on my unit are actually the best. I love them and they have been incredibly supportive. But, as an example, the other day a mid-level practitioner got angry at me in front of two other people for not following an order-set, telling me that I needed to be professional enough to ask questions if I didn't know something. I apologized, even though I was really confused because I had just checked the order-set minutes before and was pretty certain that I had done it correctly. After she went away, I re-checked the order-set and I HAD followed it correctly. She was the one who didn't know it. One of the nurses who was watching told me that the mid-level felt like she could treat me like that because I appear too apologetic. But I don't know how to avoid this. I feel as though I have lost all the confidence that I had before I came off orientation, and now I am setting myself up to have people ream me even when I haven't made mistakes. I know that they say that, "No one can make you feel inferior without your consent," but I am terrified that I really am inferior. Everyday I go home and research everything I did, and I am horrified by every small thing that I did wrong. I worry that I shouldn't be in the ICU because I am not safe enough, or smart enough, or don't have a good enough memory. I can't be the first person who has felt these things. Does anyone have suggestions on how to have more reasonable expectations of oneself? How do you know that you are safe? I know that I care, and that I care to learn, but what if that isn't enough? I sometimes feel as though the stress of the unit makes me forget all of the knowledge that I can so easily access when I'm at home.

I think that both sides are correct here. There are students who complain too much because they want to be able to pass while doing a bare minimum of studying, and there are instructors who don't think that their students are capable of any critical thought and therefore will never give them the benefit of the doubt. I have always been a good student. I was a second-degree nursing student and graduated Summa Cum Laude. My GPA was 3.97. I got an A- in one class, and I missed an A in that class by literally one question on one exam. And yes, I do blame the instructor for that course. Here are the reasons why: 1) No one got an A in the class. If no one got an A in your course, there is a problem. 2) On all exams, there were several questions where the answer directly contradicted what she had said in class AND ALSO contradicted what the textbook said. Keep in mind that this was a psych course, so many of the questions were very much dependent on nursing judgment. When students tried to question the answers chosen for these questions, she would not harbor any complaints and would blatantly deny having said something else previously and would say, 'The book is wrong.' This made it almost impossible to study for her course and was extremely frustrating. She also frequently insulted the mentally ill, which made me lose respect for her as a professor. Did I complain? I did not, and I had several reasons for it. First of all, several other students (who I respected a lot) did complain without success. I did not anticipate more success. Further, I felt that it would be a good growing experience for me to let go of my focus on my GPA. I think plenty of us know that nurses can be perfectionists, and I fall into that category. I believe the issue was with her, but I also felt that it would be wise for me to learn to move on from my frustration and to accept that sometimes one cannot be perfect/some things are outside of my control. I am happy with this decision and I do think that it made me a wise person with more ability to let go of my anger towards perceiving unfairness, although I can't deny I sometimes regret not achieving the 4.0 that I set out to achieve. In the end, I think this professor had issues that she needed to address. I am very passionate about mental health in this country and really wanted to master therapeutic communication in her course, but I think this was made more difficult to do due to the constant contradictions in her lectures. As a student, I do have responsibilities: I should read before class. I should attend class, take notes, and pay attention. I should study for exams, and take an active interest in the material. I feel that I did all of these things in this professor's course. However, PROFESSORS ALSO HAVE RESPONSIBILITIES: they should work to ensure that they are presenting factual, unbiased, and relevant material to their students; they should provide up-to-date materials, and they should listen to questions asked by students with respect and attempt to answer them clearly. I do not feel that this professor did this, and I don't think she pretended to. It is definitely not always the professors fault. I had a great med-surg teacher who people did not like largely (I think) because there was so much material in the class that it made things difficult. However, sometimes it really is the teacher's fault.

Thanks, FlyingScot, that link was so helpful! I have a feeling that this is what my instructors were trying to say but didn't. I don't want to criticize my bridge program, but it often feels as though they are saying things that aren't quite right. The other day one of my instructors said that we have CSF in our peripheral nervous system... So it seems the upshot is that alkali (usually bicarb) tx should be considered in patients with pH Thanks, again! I understand this much more thoroughly now.

I am a new nurse and am doing an ICU "bridge program" with nurse educators at my hospital. Most recently, they said that sodium bicarbonate shouldn't be used to treat acidosis because high CO2 levels cause our respiratory drive, so if we decrease acid levels with bicarb, we can cause a problem even worse than our original one. Yesterday I had a patient who had a pH of 7.09. We were (as one might expect) running bicarb like mad. We were hyperventilating him (RR of 24 on the vent) as well. Now obviously on this patient we didn't have to worry about the respiratory drive (since he was vented), but it still made me wonder about my educator's statements about bicarb. Do your hospitals use it? Is there something to what my educators said? I feel as though it is fairly standard for doctors on my unit to prescribe.

Oh my goodness, that is frickin' amazing. I can't wait to try that.

Thanks for the response! Again, I'm new so I think I'm having trouble picturing what you're describing! Are you saying that you connect three 3-way stopcocks together on the same lumen?

Thanks, Jamisaurus! I hadn't though about the secondary pushing the primary in and that's a great point! I do tend to find CVCs overwhelming, since there are multiple lumens and often several drugs per lumen. When checking compatibility of drugs, do I need to check across lumens? So for example if I have a triple lumen R IJ and I am running levo and vasopressin in one, and then fentanyl and K+ in another, do I need to check the compatibility of K+ with levophed? Or do I only need to check its compatibility with the drugs running into the same lumen?

Hey everyone, So I'm a new nurse on the SICU. I just graduated in December and I am 3 weeks into orientation. It is going well-ish (everyone says I am too hard on myself), but I worry a lot about things when I go home. I'm told that's normal. Anyways, one thing that I could really use guidance on from more experienced nurses is how to clean up lines. For example, last night we had a super sick admit on our floor. This lady had an Hgb of 4.0 and had multiple pressors; we were measuring CVP, PA, bladder pressures, the works. However, when she arrived from the PACU, the lines were an absolute disaster. She had two sets of shock pads on, tons of extra lines -- just so confusing. I was focused on doing our intake assessment, but one of the other nurses managed to sort that whole mess and make it workable. Later, I was wondering: how did she do that? I know this is probably a dumb question, but I find that often its the dumb skills-related questions that are tripping me up because I'm worried to do something that seems basic in an un-safe way. So say a person is on lots of pressors and has a whole bunch of lines that are untangled. How can you disconnect and untangle them safely? What about the transducer lines? Can I unplug CVP, PA, and A-line cables to detangle them? What do you guys do? Any tips on how to keep lines organized when your patient has a lot of drips? We obviously use labels in our ICU, but as a new nurse I still find it hard to keep track of every line when they tangle, and I worry that I may not know all my access points in an emergency situation.

Thanks so much for the response! I think I definitely like to see my patients get better, which is one of the reasons I was concerned about MICU, but then again, "variety and complexity" sounds great! It's hard for me to say what I have enjoyed the most in school so far, because I generally tend to enjoy it whenever I get a complex patient, whatever the issue. I would say the most interesting patient I have had so far was one who had an unexplained electrolyte imbalance and thus needed four different lines which were being continuously monitored and changed. However, I have the impression that I would get patients like that on most ICU floors, correct? I think it is difficult to decide on my interests because I still have had only a small amount of exposure. Honestly, I just find it interesting whenever I get to do anything that requires me to use knowledge of pathophysiology. (I know that every patient requires knowledge in order to understand the problem, but for some patients you really need to use knowledge in order to treat, and I love that).

I am a nursing student in an accelerated program and have been told by my clinical instructor that she would support my working in an ICU for my senior practicum. I have been working very hard to make this happen the entire time that I have been in school, and I am really excited. I mean, REALLY excited. So I'm wondering: any input as to what ICU I should choose? My options are CCU, neuro ICU, MICU, SICU, and burn ICU. The hospital I would be working is known for cardiac, so that seems like the obvious choice, but I would really like to explore my options and I would love some input.

Found it. Thanks!