thatoneguyRN

Thank you for the info, I really appreciate it.

1. Nurse to patient ratios 2. aides do they have them what can they do 3. opportunities for advancement 4. type of work culture 5. what is thier turn over rate, more is typically an indicator that the unit has some issues and nurses are jumping ship 6. how long is the orientation, can you get more if you feel like you need it 7. how can you get a new preceptor if thier teaching style and your learning style dont mesh (the politically correct way of saying your not getting along with them or getting what you need from them and what to do about it) I feel like most of the questions you want to ask in the interview are related to figuring out if the unit is going to be a good fit, the other clinical stuff you get at the bedside during your orientation. This is just a short list, if I can think of anything else I will update, good luck ICU nursing is kinda bad a$$!

Hello nurse peoples, I work in critical care now, in a big busy cardiac surgical ICU. I have about 2 years of critical care experience. We have lots of devices and really sick people. I love it, and learn a lot but don't see myself here in ten years. I would like to get into the out patient preventative side of things and that is what has me interested in doing a FNP program somewhere. However the idea of starting from scratch in another specialty if my end goal is going back to school doesn't necessarily appeal to me, but I am so specialized now, I feel like I might benefit from taking care of a more diverse patient population. My question is would it be a good idea to try to get into an out patient setting say an ambulatory care position or would it be a good idea to try the MICU to see a greater variety of disease processes and more medical management of patients versus surgical? Or am I going to get enough of all of these experiences in clinicals through school that it will not be necessary to change my specialty prior to going to school assuming I get in of course? Thanks for any info, thoughts, opinions ect, all are welcome and much appreciated. I am in the research part of trying to figure out what I want to be when I grow up here and would love to hear from some people in FNP programs or practicing FNPs. Thanks again.

I agree about teaching during teaching moments; however, when someone is coding if you're not keeping their maps up, get out of the way and let someone else do it and a word of advice to anyone...don't take anything personal that is said in a code. Tensions run high and that is that, the most important thing is getting the patient back. Also as someone already pointed out, they can't get more dead so when alone until help gets there something is better than nothing! My two cents :) That being said shouting and disorder should not be tolerated, it is ok to say everyone calm down. I have worked on the floor and in an ICU, usually the ICU codes run much smoother, however the ones on the floor got the job done too. In the ICU there is so much more support, and that is part of why they are pretty smoothly run I believe, also if you're breaking ribs you're doing it right! That is all...

1:1 RN with a perfusionist, though the perfusionist may watch multiple ecmo patients.

I think I got my witnessed and unwitnessed wires crossed. The article I looked at was for witnessed arrests as you guys pointed out. It makes sense.

Interesting, and thanks. It does make sense that it would be for witnessed arrests and the piece about preventing reperfusion injury is fascinating. I will have to look into that. Also part of why we didn't cool may have been that my patient along with following commands converted into PEA...oh joy, and then we got ROSC after the secondary temp pacer kicked in, with some help from epi and good old quality CPR. The temp/perm did not seem to be doing it. One sick patient, but I am encouraged by your story JSBSN, I hope this patient does equally as well.

Hello all you critical care nursing peoples, I had a patient try to go meet Jesus on me the other night. Witnessed cardiac arrest, we got him back within a few minutes, and they were following commands before I put them back under with some propofol as they was emergently re-intubated. The charge nurse said he did not meet criteria for cooling as he we had a good neuro exam before he was sedated--he was following commands. I have done some research and found that there is good evidence that therapeutic hypothermia improves outcomes for pts with unwitnessed arrests, but not so much on witnessed and not a lot on the reasons why, and as the rest of my night was spent checking and re-checking labs, supplementing electrolytes like it was going out of style and generally being busy. I didn't get to ask. So my question is do any of you have the reasons behind why we cool comatose post-arrest pts after return of ROSC? Is it to protect the brain/heart tissue by lowering metabolic/oxygen demand or is there some other cool (heh, heh) reason? Gracias in advance.

My BSN program in Portland, OR did not, and the reason cited was litigation concerns...which seems silly to me but there it is. It is an issue, as it can be seen as one of the big tasks and cause for some stress if you have not had the time to get sticks in school or a clinical rotation. But that being said my experience is don't worry once your on the floor and get your feet under you then just make time to start IV's if you pt needs one or someone elses does go and try once. Find out the nurses who are good at starting IV's and have them walk you through it. Also if you can get into an ED or ICU if that is what floats your boat your will have many, many opportunities to stick people as we do all our own sticks usually. Also it really depends on where you're at, if you're working in surgical units your patients are going to be all lined up and you will have more access than you know what to do with and even if you have started a bunch of IV's in the past you will get rusty as you will not be using the skill as much. And in most cases unless you are in the ICU or the ED there are IV teams in many hospitals that will come and start IVs for you as you will be busy as hell with all the other patient care and medication passes stuff. This is not an excuse to learn! I would still advocate getting this skill down. However in my humble opinion its just that, a skill, and you will get it with practice and unless you are in an unit that is doing a lot of them as is the case in an ED, its not as big a deal as you might think because of reasons stated above, plenty of access, IV teams, ect. Plus if you are in a unit that starts a bunch of IV's you will be a pro in no time. I started zero IV's in school and am now someone who people go to for hard sticks, and all I did was make time to try and start them. I am now I am pretty good--I wouldn't sweat it .

Yeah it does, thank you for the input. I am originally from california and eventually want to go back but am trying to figure out if its worth it to do so with the high cost of living assuming I could find a job eventually. But its good to have a better idea of how the pay structure works, sounds like you have to put in your time. :)

Thank you for that input, I have some decisions to make and it helps to look at it not as a problem but as an opportunity. Its hard as the moral on my unit right now is pretty dismal and its easy to become negative and get tunnel vision. Thanks for another perspective.

I want to clarify what bad means, I work with some very dedicated RNs who bust their butts and we give excellent care. It is not my co-workers or the pt population, both of which I love, but the overall work culture which is made not-so-much fun by a few nurses who are part of the power structure of the unit, who have been here for 20 + years and the management which it seems just wants warm bodies. Most of the good RNs are leaving and this is the problem. Now this is a CTICU in a very big and somewhat prestigious teaching hospital. We are 20 + beds and they are going to open more. We just moved from our old building into a brand new shiny one. We don't have the nursing staff for the beds we have open now and moral is bad and getting worse. We are losing a bunch of people in the next few months and that is when management wants to open the new beds. Recipe for a not fun working environment, as most of the people leaving are experienced ICU RNs. I came to this unit from CT-step down because I wanted the challenge and I wanted to put in my dues and get to the place where I could take care of for instance, the ECMO pts and fresh post-op on RVAD and IABP with rocket fuel, the sickest of the sick. But now that things have taken a turn for the worse and there is a mass exodus started, I am, to be honest, scared to go to work. I am soon to be one of the more "experienced" RNs as an older more experienced co-worker joked the other day and I have about 9 months of ICU experience! So my question is how long should I stay? I don't want it to look like I was job hopping but if we lose all our really experienced staff this is going to be a scary place to work. I will have a year in january, should I look for another job then? I want to get to where I would be able to take care of the really sick patients, but that will take at least two + years as I will only just then be getting comfortable in the unit and with the patient population devices gtts ect. I hate going to work now as I am worried about getting an unsafe double, no one to help out ect and it is looking to get worse. I want to get into a unit where I can put in my time and get really good at my job, but this unit is sucking out my soul. Thoughts?

If the patient is conscious and has a pulse then they are tolerating this rhythm, it would be considered a stable tachycardia but for how long is another story, but you would want to quickly manage that condition and try to get them back in a more stable rhythm otherwise they will soon become unresponsive and pulseless. Then in the ACLS protocol you do chest compressions first on an unresponsive and pulseless pt one round of 30 compressions and then defibrillate. As torsades is a polymorphic VT r/t hypomagnesemia so you would give magnesium, I believe its a loading dose of mag and then starting an infusion. I am relatively new to the ICU as well and I been doing CTICU for a little under a year, and CT-stepdown for a bit and I should say I have seen torsades once, but the pts had a BIVAD so their pressures did not budge and all we did was give amio boluses, two I believe and it wasn't my pt but I was helping out. If I remember correctly the pt was going in and out of VT and then had a run of torsades when I was in the room helping the nurse whose pt is was. So it can also depend on what else the pt has going on and provider preference too as I have seen things done, not by the book of ACLS in the unit all the time. https://www.acls.net/acls-tachycardia-algorithm-stable.htm Above is a link to the ACLS algorithm for stable VT and torsades is way at the bottom, now if there are other ICU peoples that have seen this rhythm more often they might be able to give you more info on how it is managed in their experience. But that is what you would do according to ACLS, basically you wouldn't start ACLS and definitely not chest compressions (BLS) until your pt decompensated and was dead ie. no pulse and not responsive. Otherwise you have one ****** off pt as others have commented on above :) Hope that helps.

I dunno but its the go to phrase for our really sick pts! Thats pretty cool you could pull tubes, to be honest I have watched the mid-levels do it and it doesn't look too complicated, but then again its one less thing I have to do so I am not complaining that we dont. Pulling an IABP would be pretty interesting, even if it was post-mortem. I have seen them pulled, and they are longer than you would, or at least I thought. Anyways thanks for the info. I guess I forget IABP is not something typically used to help get people off bypass but to help "cure" angina and usually given, like you said, post cath lab so after angioplasty or PCI stent ect? Maybe I need to go work in a CCU.

Yeah pretty normal from what I have seen, though not always do you have two patients to transfer only sometimes. Its usually one to hurry up and get to step-down then a fresh admit... This is day shift to a "t". Having to d/c two and then get one back every day would wear me out! Annnd this is why I work nights We still get admissions on nights but just not as crazy of a pace as days. The factory analogy is pretty fitting for a dayshift in the CVICU I guess! I will say though I would love to do only valves and cabgs. We do VADs, Lung transplants, heart transplants, and other lung stuff and then there is the crazy ECMO stuff which I don't do yet but I digress. Of all the above give me a cabg or valve anyday! By the way where are there stable IABP pts, I want to go work there! We see them put in because the pts EF is 15 and they couldn't get them off bypass now they are on rocket fuel maybe a RVAD and IABP...sicker than snot! I would love to learn-I am not IABP trained yet-on a stable balloon pt! Also we have PAs and NPs that pull all chest tubes and temp pacing wires, oh yeah can't forget the 2nd year residents they do this too. Do nurses do this in other facilities? We dress them ect but thats all.