LonghornChic

Sounds like you did the best you could. In the past 6 years, I’ve had 2 of my patients actually code - both were during hemodialysis. Having recently switched to ICU nursing, I’ve helped code at least a dozen patients within the last 6 months. You become more proficient with ACLS after the first few. Anytime I help with a code, I take over whatever ACLS task the primary nurse is doing (pads, CPR, meds, etc.) so they can focus strictly on providing info to the team. Codes are never easy but a good team can literally be the difference between life and death.

I worked in IMC full time 4-5 yrs ago before going back PRN last year. I filled the other years with outpatient nursing (street medicine and school nursing). I got a full time ICU job this year, received 8 weeks of orientation and have been on my own for the last 4 months. it’s been an eye opener for sure. I’m finally stating to feel a little comfortable with most procedures and learn something new everyday. I’m always afraid of what I don’t know but rely on my colleagues to continue to help guide me in this aspect.

I worked IMC for 2 years then left for a “Street Nursing” position. I left street medicine because finding ran out so I became a middle school nurse for 1 1/2 yrs. I have never felt so unappreciated and alone (professionally atleast) in my life. Despite having set hours of 0730-4 pm M-F, I still stayed late everyday to catch up on paperwork. Hardly ever got lunch. Took care of many medically fragile children with very little support. I was the only medical professional in a sea of 1000 people (students and staff). You are in an educators world so are often left out of everything. I took a very large pay cut because I wanted better hours and time off. It really wasn’t worth it in my opinion. Benefits were similar to the hospital. I left the school after 1 1/2 yrs and have now been in the ICU for 6 months. the ICU is crazy busy and not adequately staffed but atleast I can clock out and not have to worry about it. I work 3 on and 4 off. I don’t regret leaving the school.

Thank you all for your advice and support!! I’m definitely going to look into more hobbies. I feel so exhausted but I know I need to keep my mind occupied on my days off. Sadly, this poor patient ended up herniating a few days later and the family decided to withdraw care. I am reminded of our mortality and fragility every day at work. I try to cling to the very few miracle moments that present themselves.

I’m in awe of your flight nursing experience!! I am totally on board with having RN’s help RRT’s with manageable tasks when they are busy but what kind of threw me off is having someone else come assess my patient and then make the determination that vent settings needed to be made. I had previously given all of this info and requested their assistance in my original page to the RRT. I am not too sure what all the training involves but it makes me question what if the covering RN didn’t agree with vent settings? Or say if my patient was not an ICU patient but a Med-Surg patient? I could always insist on the RRT or doctor to asses if it did come to that but just seems like another unnecessary hurdle. I am fully aware that some nurses have extended understating and experience with vents and airway management but I don’t believe the crew being trained with the RT’s has that type of exposure. I just feel like the RN’s covering should stick to the manageable tasks and leave the actual pulmonary assessing/decision making to the RRT’s. I am probably just overthinking this but I’ve seen this situation play out more and more, especially since we’ve lost 2 more RRT’s to traveling.

At my current HCA hospital, we have an extreme shortage of Registered Respiratory Therapists. To help with that shortage, several nurses have been trained to assist the one RRT with things such as neb treatments, vent checks, suctioning, preparing for intubation, ABG’s, assisting with bronchoscopy, etc. Yesterday I overheard one RRT telling another RRT that he’s afraid that they will soon be replaced by RN’s and LVN’s (he was supposed to be training an LVN that day). I will say that if this is the case, I am concerned. A few days ago, I paged the RRT to come asses my vented adult ICU patient who kept desating into the 80’s despite suctioning and adjusting sedation/paralytics for vent synchrony. I increase O2 to maintain >92% while I waited on RRT. The RRT was occupied in ER assisting with an intubation so they sent an RN (whose specialty is mother/baby) to come asses my patient before he turned around and called RRT to come make vent adjustments. The reason I had called RRT in the first place is because I sensed that vent settings needed to be adjusted but I wanted to make sure the correct ones were adjusted such as O2, PEEP or TV. Sending another nurse was just a waste of valuable time. I am a new ICU nurse (not new to nursing) and feel that I rely on the special skills of RRT to help me stabilize my critical patients. But now I am worried that resource will be incredibly limited or not available at all. I will have to do my best in learning what I can in terms of vent/airway management. Is anything like this happening in your areas?

I did want to add that I had asked the MD about possibly changing to another pressor, such as Levo, that might help increase BP as well as HR but he decided that we should try what we had hanging already.

Hi all, I've been an RN going on 5 years. My first 2 years were at the bedside in IMC and the last 2 1/2 were outpatient. I recently returned to the bedside but to a 40 bed ICU unit. I had an 8 week orientation (most was COVID related) and this last week was the first week on my own. My first week was what I like to call baptism by fire. I don't really have anyone to vent to so I thought that you all might understand. Sorry for the long vent. My first assignment was a trauma patient that had 2 crani's in the last 3 weeks. She was on precedex and fent to help keep her from fighting the vent, mostly due to the large amount of secretions that caused alot of coughing. She had a fresh trache as well. Her BP was soft with SBP in the 90's and HR in the 50's. No pressors. Yesterday she spiked a fever of 103 and had increased serous drainage from her crani site. A head CT was ordered. Given this patient's vitals and inability to lay flat, I was asked to try a combination of sedatives and add on Neo for BP support as additional sedatives will bottom out her BP (she was already soft to begin with). I added a low dose of propofol, increased fentanyl, and kept precedex the same. She was still unable to lay flat without coughing and her HR actually went down and maintained in the high 40's. I believe this is due to the reflex bradycardic effects from Neo and the precedex as well. I tried suctioning her before laying her flat. I felt that increasing or adding more sedatives would make her dangerously bradycardic. I consulted with the MD about what else he would like me to do as I did not feel I was able to adequately sedate this patient and maintain her in a somewhat safe range. The MD went to the room, messed with the sedatives (increased propofol, turned off precedex, increased the Neo, maxed out the Fent). The patients HR dropped to the 30's but she was able to lay flat without coughing. He then administered Ephedrine and increased her HR to the high 40's. He asked me to leave STAT to CT. The patient was packed in less than 5 minutes and a team arranged to help with transport (RT for vent, 2 techs, charge nurse, myself). The MD gave me a syringe labeled with the remaining ephedrine and asked me to give 1 CC every 5 minutes if she dropped under 45. The team flew to the elevator, down to CT, and back in less than 20 minutes without incident. I thankfully did not have to administer any ephedrine or increase her sedation. I was so incredibly nervous during this entire time! This was my second time ever having to manage anything other than propofol or versed (my orientation was pretty limited). The critical care MD was very patient during this whole event and tried to teach me why he was doing what he was doing during every step of his actions. He even offered to go down with us to CT but we already had enough people going so he stayed and texted me while I was in CT to check in. Earlier that day I assisted this same MD with a bronchoscopy at the bedside (something I had never done either). My charge nurse, RT, and techs were also wonderful in helping me. In talking with the other unit nurses, they felt that this situation was risky but thankfully worked out. Despite the support, I can't help but feel that this was a baptism by fire and I have not even really experienced what it's like to have an unstable patient. Anyway, just needed an outlet to vent. Any recommendations for keeping a journal during your nursing career? Or do y'all just find a colleague/friend to talk to? My current friends would not understand.

It’s a relatively new area of public health. There’s very few programs like this and I feel incredibly lucky to be part of it. I’m hoping to be able to assist in expanding it. It’s a little scary stepping into this role knowing that future program funding depends on how much of an impact it has on the community.

Hi! I’m not sure where to post this but here it goes. I’ve been in nursing for a little over two years with a background in critical care. Recently moved into the public health spectrum. I’ve been working with the homeless and mentally ill at temp brick and mortar sites but will be transitioning into a supervisory position for street/mobile clinic nursing. It will be me, an MA, and a provider. Some days will be spent in a makeshift site inside a facility (church, halfway house, rehab, etc) where we haul in all of our supplies in duffle bags. Some days with community health paramedics providing care in the streets and community fairs. Some days in a large clinic RV. I’ve worked with this group before but never in a management position. We do a lot of wound care, lab draws, care packs, DME stuff, referrals, suboxone management, etc. There’s is a lot of autonomy, critical thinking, and decision making that goes along with this position. Does anyone have any experience in this? Any pointers?

Hi! I’ve been in nursing for a little over two years with a background in critical care. Recently moved into the public health spectrum. I’ve been working with the homeless and mentally ill at temp brick and mortar sites but will be transitioning into a supervisory position for street/mobile clinic nursing. It will be me, an MA, and a provider. Some days will be spent in a makeshift site inside a facility (church, halfway house, rehab, etc) where we haul in all of our supplies in duffle bags. Some days with community health paramedics providing care in the streets and community fairs. Some days in a large clinic RV. I’ve worked with this group before but never in a management position. There’s is a lot of autonomy, critical thinking, and decision making that goes along with this position. Does anyone have any experience in this? Any pointers?

Thanks! I felt some pity towards the intensivist at the end because I had a sense that this delay was due to another reason and not the one he told me about. Maybe something had recently happened that caused him to be hesitant in transferring patients to higher levels of care? Either way we both learned lessons that day.

Thanks! I felt some pity towards the intensivist at the end because I had a sense that this delay was due to another reason and not the one he told me about. Maybe something had recently happened that caused him to be hesitant in transferring patients to higher levels of care? Either way we both learned lessons that day.

Thank you! This was the first time in my career that I've ever had to go through this much stress to get someone transferred. It was definately an eye opener!

In this particular step down we can do certain pressors and very limited use of BiPap. This patient became MICU appropriate due to her rapidly declining respiratory status. The MD held off on putting her on Bipap (despite the confirming ABG's) because he was aware of the step downs limitations on BiPap. From what I know this patient was intubated within an hour of the transfer. As far as pressors go, I was trying to manage the downward trending BP's with very limited nonpressor BP support. I was basically implementing the highest non-MICU interventions allowed for this particular case. The MD was finding ways to delay the transfer while still keeping this patient "stable" despite the obvious. He straight out told me this.

I soon as he told me his "reasons" for the delay, I knew I was going to get nowhere with him. I 100% believed that this patient would code during the night, especially with her history of crashing and burning.

Thank you! I figured the intensivist had other less obsvious reasons for delaying the transfer. The RRT were not as fruitfull either because the same intesivist also attended and ran the RRT. I now see that calling a RRT (or multiple RRT's) does not guarentee my concerns would be adressed.

Also forgot to add that I was so concerned about this patient going into respiratory or cardiac arrest that I placed the crash cart in the room and had the pads on her the entire time this situation was going on. I also placed the rapid intuabition kit at the bedside. Not even the site of this caused the providers to understand how concerned I was.

Hi all! Sorry but this is a long post. I'm a new nurse (1 yr) who floats between units in our critical care department. I spend about 50-60% of my time on the CC step down unit. A couple of weeks ago I had a situation where I believe my patient's safety was severely compromised and I found myself jumping through hoops of fire trying to get her upgraded to the MICU. I will spare some details to protect privacy. My patient had been admitted for several weeks due to sepsis/pancreatitis and had been jumping back and forth between MICU and step down due to all of the sequella of her condition (liver issues, perfusion issues, clotting issues, etc). One week she was improving and the next she would crash and burn. When I first received her, the patient was on 3L NC, AOX3, unlabored breathing, HR in the 80's, afebrile, and with a BP that was on the softer side (low 100's). Assessment wise her abdomen was distended with hypoactive BS. She was jaundiced throughout. At around noon I saw her heart rate increase to the 140's sustained. She was working with PT at the moment so I did not think much of it. She did not appear to be in any distress at the time. 20 minutes later, her HR is still elevated at rest. This time her breathing appeared more labored and I had to increase her O2 drastically to 15L on a NRB. Her BP was normotensive but she had a low-grade fever now. I immediately directly called the intensivist and received orders to r/o a PE amongst other things. The scan was negative and the patient was stable. Upon our return, her oxygen demand increased to 40L heated high flow and she was now unable to maintain adequate blood sugar control (30's-300's within an hour). I called a Rapid and was given orders that would assist with BS control and nothing else. I expressed my concern about the patients declining status and the need for a higher level of care. I was told by the intensivist that the patient was stable enough at the moment. I was worried that this patient was going septic again or had developed peritonitis due to a now firm abdomen and almost absent BS - I told the MD this. Then 3 pm came and the patient's blood pressure began trending down (into the 90's, high 80's with decent MAP). She remained on the same oxygen level. I again spoke with the intensivists - just monitor. I spoke with the specialist - just monitor. I spoke with a different provider on the case - just monitor. At 4 pm her O2 demand was increased to 60L HHFNC with 94% FiO2. The patients mental status seemed to be declining as well. Her blood sugar was again hypoglycemic. Her BP's was in the 70's-80's. Still tachycardic. I called another rapid. This time I received an order for blood pressure support (not pressors). I again expressed my concerns and need for higher care. I asked the doctors directly the reason for the delay and I was told in certain terms that they were trying to wait it out until the next morning. I can't really go into details about that part but let me just say that their reason for this was nonemergent and ridiculous. During this entire time, the house sup and the charge nurse were also doing their part to try to get the patient transferred through other avenues. At around 5:30 pm and after exhausting almost all of my resources I decided to call the medical director. I explained the situation and my concerns. Within 10 minutes the director was at the bedside and completely agreed with my concerns. At 5:45 pm this patient was finally transferred to a higher level of care. I transferred the patient and was greeted by the intensivist at the MICU. let me just say that he was NOT HAPPY that I had gone above him to get this patient moved. I spent nearly 6 hours taking care of this one patient. My other 2 patients were still taken care of (wonderful teamwork!) but I felt they were much more neglected due to my snowballing situation next door. One lesson I learned is that I need to be more aggressive with my concerns. I feel that this delay was completely avoidable. Was there anything else I could have done? Now I every time I see this particular intensivist, I feel like he still is very angry with me. It doesn't matter how he feels towards me but I do think it has affected our professional relationship. Sorry for this long post!

In my ICU stepdown unit we sometimes assign RN's to be a "task nurse" when we're short a CNA/PCT. The task nurse basically does all the tech work plus pass meds, start IV's, Foley's, etc. if the patients main nurse is busy and needs a little help. It's a lot of work but it's a good way to keep your basic nursing skills sharp. I haven't done it yet but I would like to do it. The task nurse does not have an assignment persay but he/she does assist the main nurse.

If de-escalation doesn't work then I assess their mental status. If they are pretty oriented and know what they are doing then I say "since you know what you are doing then I should inform you that hitting a nurse is considered a felony". I ususally get an apology afterwards and make sure to document that interaction. We let ourselves get abused too much.

APS seems to think so. My neighbor is 83 years old and moves at a snails pace due to his parkinsons BUT he moves, even if it does take him an hour to get out of bed and into his wheelchair. He can apperantly feed himsekf also even if that means a loaf of bread and old ham slices for breakfast, lunch, dinner. He doesn't shower for days (I am sure its more like weeks on end), BUT he showers.

I've been on the other side of that fence...the neighbor calling authorities. I have a very long history with my neighbor (his house burned down, he stayed with me while we helped with reconstruction, I am MPOA due to his own family issues, and sooo much more). He lived by himself with his dog for the last 3 years. I took him grocery shopping, his doctors appointments, and cleaned his little apartment weekly. Due to his worseing Parkinsons (partially wheelchair bound), I got home health and meals on wheels involved weekly also. His family started coming around this last year. By involved I mean coming around the 1st of the month and leaving around the 3rd...usually long enough to drain him of his monthly limited income. It got to the point where he could no longer pay his utilities or buy groceries because his family robbed him monthly. They literally robbed him (took his ATM card and withdrew hundreds). I called APS four different times. They did nothing. Home health called APS. They did nothing. He started falling more often. The last time he fell I took him to the hospital TWICE in a week. He got discharged with "bruising" but no fractures. I finally called EMS and had him transported because he was in so much pain that he could no longer get out of bed. He was covered in feces/urine when they showed up. He was admitted to the hospital with a minor diagnosis while waiting on LTAC. APS got involved and also agreed with going to LTAC. Honestly LTAC was the best thing that could happen to him given all the things that were happening. He was of sound mind and understood that LTAC was the best thing for him. He was there for about 2 months until he found out his family was trying to sell his home. He discharged himself from LTAC (bribed his son to come "sign" him out) and is now back in the same condition he was before. We still check on him daily. I take him food daily. I am very afraid that he will be dead one of these days. Unfortunately being at home by himself, no matter how much he missed his home/animals, is not the best thing for him. He needed LTAC.

I think this will be something I will bring up to my manager when I talk with her next week. If their part time hours are doable then I might stick it our with them. I know of a couple of nurses that work 7 am - 3 pm a couple of times a week. Most of those nurses have been here for years though so they probably earned those hours. Doesn't hurt to ask I guess.

We are furtunate enough that his employer has allowed us to use medical leave of absence. This should cover us for a bit until he can return to work (he'll be abl to, he just needs some extended recovery time). We also have some emergency savings to get us through. The main concern is my children needing care at night and after school. My husband was responsible for that part but will mostly be unable to do it for the next several months due to his inpatient status. I have very little experience as an RN but the employers I spoke with seem optomistic and willing to train. I made sure to explain how green I actually was (in terms of nursing experience) before I even set up an interview with them.