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marienm, RN, CCRN

Burn, ICU
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marienm, RN, CCRN has 8 years experience and specializes in Burn, ICU.

Second-career RN working nights in the Burn ICU.

marienm, RN, CCRN's Latest Activity

  1. marienm, RN, CCRN

    Re: Weight based critical drips

    My hospital uses whatever weight the provider chooses (admission weight or current weight). We don't typically update these orders daily...our official policy says it should be changed if the patient has a 10% or more change in their weight. We used to focus a lot on trying to get the providers to only use the dry weight and to "fix" the weight in the order but honestly it seems to be a losing battle! Like another poster, our pumps have the weight programmed by each channel and they have to match the order exactly so that the pump can communicate with the EMR. I take comfort in the fact that most of the gtts that ICU nurses titrate are titrated to a measurable response (pain scale, sedation, blood pressure, HR, coags). So even if the weight isn't exact you will adjust your titration based on the response. A RASS of -2 is -2 even if the propofol order is based on a 70kg weight for a patient who now weighs 80kg. If your max dose for that weight isn't enough to sedate the patient then you probably need a different drug rather than worrying about correcting the ordered weight so you could give a tiny bit more. Obviously there is much less wiggle room with peds (I only work with adults) and it a patient has truly had a significant and rapid weight change (total leg amputation) then it's worth pursuing correcting the dosage weight in that circumstance.
  2. Tricia is probably right but if continence/preparedness is actually the concern, could she use a Purewick? Or if she is able to ambulate, up to the commode every 2-3 hours while awake. We have patients who we don't allow to use bedpans because they NEED to get moving. The M.D. will place orders to this effect.
  3. marienm, RN, CCRN

    New RN Age

    I started in an ICU at 34. There are days I feel my age (so much back pain!) but honestly I move faster than some of my younger co-workers! (I've always been a fast walker...maybe not as fast as NurseSpeedy though!). I work 12-hour night shifts and always have. Consider, though, that your preceptor and even manager may be younger than you...maybe by a lot! Not only will they be teaching you the nuts and bolts of the job, they'll be teaching you the "norms" of your hospital and your unit. If the thought of a 22-year-old telling you how to answer the phone correctly or coaching you on therapeutic communication gives you hesitation, pay attention to that feeling! You're not wrong or right to have that feeling, but you need to be aware of it, do some introspection about where it's coming from, and not let it get in the way of learning your job an interacting with your co-workers. [Full disclosure: I am posting this because this was a process that I myself needed to go through! I came from a semi-academic setting where I was used to telling the 18-22-year-olds what to do, not the other way around!]
  4. marienm, RN, CCRN

    Vocera! Can you talk to...?

    We have Secure Chat in our EMR but we don't use it the same way as the Vocera. Vocera tends to be for immediate stuff, like new patients being assigned by the bed admin, RRT coverage, and "can someone help me boost bed 8?." We use Chat for non-urgent conversations with providers (renew an order, pt has mild headache, do you want routine CBC on this pt today?). I guess some staff use Chat like instant messenger to chat with friends (risky idea, IMO) but for actual *work* purposes we use them differently.
  5. marienm, RN, CCRN

    Vocera! Can you talk to...?

    When the voice recognition works, I like it. I also like being able to assign yourself to different user groups on the fly...so if you float, you can join the new unit's group. (This probably depends on how your hospital has set up the system, though. For example, I can add myself to my unit and also to the "charge nurse" channel for the unit, so anyone in the hospital can call "Burn unit charge nurse" and they will reach whoever is in charge that shift, assuming the charge nurse has assigned themself to that channel.) Like any system, training is key (I see a lot of people talking into the bottom of their vocera...not where the microphone is...and then frustrated when it doesn't work. Or they use the wrong voice command to join/leave a group and then blame the vocera.). It's also not great at understanding accents. I also like being able to decline calls by voice/hands-free, since we wear contact gowns on my unit frequently! I've never worked with any other system...the Ascom phone system that people describe here where a patient can call you directly on a phone (while you might be wrist-deep in who-knows-what) sounds awful to me! I'd rather they just used their call light and hope a co-worker can check on them sooner than I can. But if that's what I had learned to use, I guess I'd get used to it.
  6. marienm, RN, CCRN

    Biology or Chemistry

    Biology will probably include the functions of the cell and the Kreb's cycle, so it might help prepare you for A&P.
  7. marienm, RN, CCRN

    BIS monitoring and sedation titration

    Finally got a chance to look...our default orders are for a RASS score (filled in by the provider). They could choose to remove these instructions and replace them with instructions for a BIS score, but I don't think I've ever seen them do so! So, OP, you're not alone!
  8. marienm, RN, CCRN

    BIS monitoring and sedation titration

    Our target BIS is usually 40-60, where 100 is fully awake and 0 is completely unresponsive. You need to monitor signal quality as well as the score (our EMR has a place to chart both). I would titrate my sedation infusion to keep the resting patient on the target range. If PRNs are needed for turns or proning I'd ask for that order as well, but I'd prefer the patient to be sufficiently sedated all the time, not waking up and then being knocked back down with a PRN. (I don't have EBP to cite for this, though.)
  9. marienm, RN, CCRN

    Should I quit nursing school?

    Many schools are allowing students to take time off without penalty right now...can you take a semester off to think about things (and maybe when you come back, in-person classes will have restarted and you might feel less alone?). Definitely talk to a guidance counsellor about your options...it might not be all-or-nothing. When you're at the point of dreading everything about school, though, it sounds like you at least need a break. Can you get a part-time health-related job? My hospital hires people with no healthcare experience to be patient safety sitters and basic care aides. It's not the same as being a nurse but it might help you see more of the nursing world...and either you will confirm your feelings that it's not for you, or you'll relieve some of the anxiety over "unknowns" about doing clinicals. (Even if you don't want to be a hospital RN, that's where your clinicals will probably be.) Or, if you decide not to take time off entirely from school can you take time off from the nursing program? Focus on other classes (writing, management for the arts, etc...) to get a little more exposure to these areas? If you're in a BSN program maybe they can count as electives? I came from working in the arts (with a BA) for a decade before going back to school for nursing. And then after working for a few more years I got my BSN. I don't regret my path but it involved a lot of redundancies (who needs 2 bachelor's degrees??) and extra work. In my part of the country a nursing degree and licensure is probably one of the fastest routes to a solidly middle-class salary with many opportunities for diverse employment with a few years of experience. I know that's not true everywhere, and I also know that money isn't everything. But the older I get, the more I see that money and job security make a lot of other things easier. Could I have convinced myself of this at age 21? Probably not! Good luck with whatever you decide. You can go back to school later if you change your mind...it might involve more hassle, but you can do it!
  10. marienm, RN, CCRN

    Sick all the time first year at the hospital

    I started as a night shift nurse having left a career working a support staff at a local university. I get less sick, less frequently in the hospital than I ever did working with mostly-healthy college students! I attribute it to gelling my hands all the time (this was before universal masking became a thing in 2020). Not discounting your experience, of course, I just think it's funny how infrequently I get sick. And since we started universal masking a year ago, I don't think I've had any respiratory illnesses at all. (Intermittent GI things which seem to be chronic/anxiety-related, and chronic headaches, but no sniffles or sore throats!). Sorry you've had a rough year.
  11. marienm, RN, CCRN

    I’ve working in the ICU for 6 months and I feel miserable

    Not all ICUs are like that, especially not every night. I will point out that undoubtedly some of this is harder because you are new and things do get easier with practice. Your skills (like blood draws), but also your intuition and knowledge of the building/medical practices do get better with time. But when you have 3 to 4 patients per shift you have no time for "practice" and you are basically praying that everything goes right the first time, which isn't reasonable. Patients are hard sticks, feeding tubes come out right before med passes, patients go into A-fib, etc. It also sounds like everyone is so busy that no one can even try to help each other...can you propose being someone's buddy so you commit to helping each other turn and bathe rather than looking for help each time? At 6 months in you are probably *barely* getting to the point where you can kind of look at a patient situation and know what's coming. (So your patient has new abdominal distention, emesis of tube feed, no stool x3 days, fever, white count, increased RR, etc...drain their belly and you're probably going to CT so you should look for a stretcher now rather than scrambling.) But to me it seems unreasonable to make a nurse with 6 total months of experience respond to RRTs. I don't blame you for looking elsewhere but I (personally) would be hesitant to get stuck in another 2-year contract. I'm actually still working at the hospital that hired me as a new grad but I wouldn't have been able to promise that when I was hired. Can your current hospital move you to another unit without breaking your contract? They should be invested in you...at least a little bit...and try to keep you if they can. (On the other hand, they won't and can't care more about your welfare than you do, so you have to be your own advocate in this regard.) Or, even though you don't want to pay back the $10K, *can* you pay it back? I hate to sound blase but $10K is not much compared to your mental health. Good luck with your decision. I don't think this means you aren't cut out to be a nurse...but getting out of this situation before it completely saps your *desire* to be a nurse might be a choice you have to make.
  12. marienm, RN, CCRN

    Infusion of Meds Question

    I check compatibility all the time on Lexicomp. Hopefully your co-workers do too, but it doesn't hurt to double-check it at the beginning of your shift to make sure the setup the previous nurse left I works. Definitely check when new meds get ordered. If you hospital allows it, you can also infuse certain meds via the CRRT tubing (either pre- or post-filter, depending on the med). We commonly run heparin gtts this way, or blood. (We usually have dual-lumen vas-caths, no third lumen available.)
  13. marienm, RN, CCRN

    Anxiety Over Past Mistakes

    Burn nurse here: From a practical standpoint, if you had burned his feet it would have been apparent quickly. He would have had redness or blisters or sloughing skin. It's not something that would only have shown up several days later. (Maybe several hours later, but you washed his feet on different days so you would have seen the problem.) But I get that it's hard to let go of the feeling that something *could* have gone wrong and you were just lucky it didn't. When I was really new I accidentally took the luer-lock connector off of a PICC line when disconnecting the IV tubing. Then I left the room. The patient could have bled out (over a long time) through this unclamped line, but fortunately it must have been positional and it didn't bleed. When I saw the problem I cleaned the hub and put on a new connector and all was well but I was still shaken up. And I've never done it again! Now I tell this story to new co-workers who have made a mistake and are convinced it's the end of the world. I don't want new people to feel like they need to be perfect or can't admit a mistake...that only leads to more (and bigger) mistakes.
  14. marienm, RN, CCRN

    Difficult AMA situations

    Re: the patient with wounds...after addressing pain and anxiety (maybe she needs sedation?) for wound care sessions...if she still doesn't want her wounds cared for, then maybe a palliative consult is needed? Palliative care at my hospital isn't just end-of-life care, and they are good at talking patients through the logic of establishing goals of care. I think palliative services should be involved any time the patient wants to leave specifically because they can't tolerate the medically-necessary care. If the patient elects to become comfort-care-only, this could also open up placement opportunities (nursing home vs rehab vs hospice house.) It will still be challenging if there's no safe discharge plan (I don't think hospice will do a home visit to a car).
  15. marienm, RN, CCRN

    Paralytic and Sedation

    I've never done it that way either...but based on patients coming out of paralysis from the OR, I'd say bolus doses wear off in an hour or two. Obviously it will depend on the patient's metabolism if they've been on a drip for a long time. But maybe start slowly weaning after a couple of hours? (Or sooner if you start to see spontaneous respirations on the vent.) I'll be interested to see what others say from facilities where this is the normal practice!
  16. marienm, RN, CCRN

    Paralytic and Sedation

    How are you monitoring the paralytic? I'd wait to turn down sedation until I was back to the patient's baseline Train-of-Four. We also use BIS monitoring for sedation so I would titrate down if the BIS showed they were over-sedated (and obviously no other clinical signs of under-sedation.)