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Emergency Nursing, Critical Care Nursing
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TexanTough has 7 years experience and specializes in Emergency Nursing, Critical Care Nursing.

Texan: Born and raised.

TexanTough's Latest Activity

  1. TexanTough

    Intubation - confused about orders

    " However, she gave me direct orders: "you must follow exactly what the physician tells you to do," plain and simple. " RnExplorer: Your charge nurse has done a great disservice to you by saying this. (Warning: Soapbox). Yes you are a new nurse and may not have the clinical background/knowledge base to question a physician. However, if you have this visceral feeling something doesn't 'seem' right, by all means question it. I don't care if it's the chief of cardio-thoracic surgery barking orders. In no way should you ever blindly follow a physicians orders. Your role is to question and critically think about the global implications of what is about to happen. You should not be giving a paralytic first. The only exception would be an already obtunded patient who risks losing their airway in the immediate. Even then, most providers will administer a sedative first to unresponsive patients so long as their is little risk for further hemodynamic insult. I see suggestions of being a cutesy nursing and 'suggesting' a dost of etomidate. I cut out the cutesy and simply say, " Let's give a sedative first please and then we will talk our paralytic dosing." Beware the charge nurse that tells you to do whatever a physician says.
  2. TexanTough

    Tips 'n Tricks: Pearls the Newbies Need to Know

    -You can't dilute valium. -If families are going to be in a room with a patient and are capable, utilize them to assist with the patient's care. -Label your meds as you draw them up. Which syringe is zofran? Which syringe is 2mg Dilaudid? -Don't be timid or a doormat. Be assertive if you are advocating for a patient (especially in a teaching hospital environment). -Know your stuff. This comes with time, but if you have a question, ask a provider. Don't ever say "I don't need to know that." You never know when your clinical proficiency will prevent a provider from killing someone. -Along the same lines as above, if you don't know something...ASK. A great approach is to say, "refresh my memory on ____" if you feel intimidated because you don't know something.
  3. TexanTough

    Learning sick vs. not sick

    Unfortunately, it's one of those things you acquire with support and assistance from your coworkers. When I was new, I asked a lot of questions about the 'worst case scenario' so that I could gain a sense of what to be prepared for if the S hit the F. I have taught people who just didn't get it and were focused on tying the back of a gown while someone was in respiratory distress. I do feel that some catch on earlier than others (or some never catch on).
  4. TexanTough

    ESI Triage concerns

    *Sigh* This is a huge source of frustration for me. First and foremost, facilities where I have worked will let green and inexperienced nurses in triage. This results in an ESI of 4 assigned to the full blown aids patient complaining of dental pain who has a HR in the 120s, is febrile, and has a muffled voice. Said patient marches off to fast track where I am now drawing BC x 2, sending the patient to CT of the head and neck, and starting broad spectrum abx. I'm done ranting. Now for the question at hand. If your nurses are truly following proper ESI scoring, it should be noted that PAIN alone can make someone a 3 vs a 4. Also, I'm a little shocked your facility does not utilize a 'fast track' for ESI 4s and 5s. This usually decompresses the waiting room of ortho/musculoskeletal complaints. If your facility truly pulls back by acuity, there needs to be a balance between length of stay AND acuity. There are several matrices available online to assist personnel with this. In terms of belly complaints. The abdomen is a veritable pandora's box. Your patient could have anything from pelvic inflammatory disease to and ileus to a dissection. This is why abdominal pain (at least where I have worked) should not be dismissed.
  5. TexanTough

    Stop the (Deskilling) Merry-Go-Round, I Want to Get OFF!

    I really beg to differ. We have dumbed down the expectation of nursing clinical expertise. Instead, we are expected to carry out all tasks easily performed by ancillary staff and cannot focus on important trends or assessments. This is far more dangerous to patients. If you as the primary nurse can't see the rising mean airway pressure in your patient next door because ethel takes 40 minutes on the commode and cannot be trusted to be left alone, this is a problem. If you cannot take note of your intubated asthmatic who suddenly stops wheezing because Jim Bob needs to be hand fed, this is a problem.
  6. TexanTough

    Stop the (Deskilling) Merry-Go-Round, I Want to Get OFF!

    I have to be honest with you, I do not want to be the sole person responsible for toileting and/or bathing my patients. I am often titrating drips, trending blood gases, and ensuring appropriate tests/labs/treatments are ordered. You cannot explain to a non-medical family or patient as to why their bed pan needs fall low on the totem pole as I've just started a third pressor, bicarb drip, see neuro changes next door, or noted new onset bigeminy. It is my understanding that the registered nurse role is intended to be that of a clinical leader and expert. The RN is to supervise and manage their assignment while delegating things such as baths, toileting, and providing creature comforts to that of ancillary staff. In my humble opinion, it is often a waste of my brain power to spend 40 minutes in a room doing these tasks unless it's pertinent to the chief complaint (GI Bleed, Extensive skin issues). If I am stuck in a room, I am also not adequately monitoring my other patients.
  7. TexanTough

    New CEN exam

    Two words: PASS CEN. Chuck the book itself and utilize the questions by category/system. It was truly invaluable and I recognized a lot of similar question structure on the test itself. Also, I had several questions about epidemiology (TB, Strep) Mostly about how long someone is contagious. I cannot say this was my strong point. The only other advice I can give is that if one aspect of an answer appears incorrect or illogical, the whole answer is wrong. Make sure you read each answer option carefully as 4/5 components might be correct but one is wrong. If you happen not to do well this go around, I would wait until you are at your 2 year mark to test again. It will be very helpful. Good Luck!
  8. TexanTough

    I need some advice

    I understand the point you are trying to convey. I do not take issue with repetition of so called menial tasks *IF* there is a clear reasoning/point behind them. Do you not think I made sure my trauma bays were stocked, calibrated, all systems go every morning and every trauma thereafter? I was very meticulous on things that mattered the most. I do not think I am above a sheet change or the nit picky tasks required of me. However, I do not logically see them as an efficient use of time or improving patient outcomes. Flight checks and a culture of safety directly impact the mission and/or patient care. Checking and calibrating equipment along with ensuring you are stocked, locked, and loaded all have a direct impact on patient care. When I say I 'think differently' than my peers, here is a classic example. A person arrives from the ED. (Most likely indigent or homeless.) Everyone is fixated on how bad they smell, contact precaution swabs, and the general uncleanliness/disorganization. I am fixated on a map of 40, poor pallor, and a heart rate in the 140s. The nurses here hone in on getting someone "situated" rather than stabilized first. It's not that they are poor clinicians, it's that they are very used to a situation where everything is in it's place before any interventions. Not every day is a scene flight or bloody trauma. I realize those comprise a small % of actual transports. However, my practice is patient centered and to maintain a homeostasis of sorts. I enjoy many aspects of the ICU and have gained valuable exposure to the long term management of the critically ill. In many ways my post is a 'vent' of sorts and isn't meant to demean critical care nurses or 'whine.' The assertion that I cannot acclimate is false. Clearly, the heart of emergency nursing and the mastery of it is acclimation/adaptability. I have acclimated to the environment I'm in, but it is mentally draining to have a group of peers who prioritize differently. The comment about having an ICU doctor holding my hand. I currently do not partake in hand holding nor will I ever. I am considered 'brash' by some because I am so forward and impatient with twiddling of thumbs by residents. I will have all appropriate labs ordered, gtts in hand, and say "these are our parameters, unless you vehemently oppose, want to put those(orders) in?" In closing, I get your point. I know that not every task is fun or mentally stimulating. I'm simply reaching out to see if others have had the same experience. You haven't crushed my career goals. I think I will stick it out and suck it up for now. (With the knowledge that my heart will always be in emergency nursing.)
  9. TexanTough

    I need some advice

    I was an ER nurse for several years and recently moved into an intensive care setting. I did this to make me a more desirable candidate to become a flight nurse. As much as I am learning in the ICU, I am clearly unlike the rest of my peers. My brain does not work the same way as my coworkers. I find myself hating the attention placed on ridiculous details. For instance, you bathe a patient (which I don't mind doing) and get them all squared away. The doc wants a gas at change of shift. You pull blood from an art line and get a tiny spot on the sheet. In this ICU, a full sheet change must happen if this occurs. My question is this: It's been a few months and I find myself enjoying much of the complex pathophys and trending labs etc... But the menial tasks are already wearing on me. Technically my obligation is roughly 2 years to the ICU and I'm afraid I can't see myself hanging on for that long. Do I run back to the ER (where I belong!)? Do I stick it out and suck it up? Any thoughts would be greatly appreciated.