GoldenFire5

When you come off orientation, you're not expected to know everything. Your charge nurse and resource nurses will expect you to ask questions. If your patient is crashing, they will want to know about it. At the beginning of your shift, take 5 minutes to think about worst case scenarios. What is the worst thing that could happen to your patient? What would the beginning signs of that look like? What would you do? If you are still on orientation, you need to ask your preceptor about worst case scenarios *now*. Review them with her for each patient. When something unusual or terrible happens on my unit, I still ask - how did you know it was happening? What were the early signs? So when your patient takes a turn for the worse, don't panic, get a set of vitals while you're thinking about what could be happening. Think of urine output as a vital sign, too. Do you have protocols for standing orders? Know them cold when you come off orientation. Review what's going on with another nurse. Good luck!

How was the urine output? Did it drop off when the night shift nurse put the cuff on the leg and stopped the pressors?

You have a great opportunity for a fresh start. You should receive some sort of orientation at your next hospital to learn the flow of how things work and how the RNs interact as a team. >She told me that I should have taken charge of my patient care and directed them to what needs to be done. I would take this advice to heart and become more assertive and directive at your next job. You're presenting yourself as having 3 years of experience... the nurses at your next job will expect you to know what you're doing. And take the phrase "I don't care" completely out of your vocabulary. It will almost always be misinterpreted. Good luck.

http://www.lakesidepress.com/pulmonary/noninvasive/venousCO2.htm

That is a real life "there is a fracture, I need to fix it" story.

You can always discuss the worst case scenario for each patient and what your action plan would be.

Any creepy, crawly bugs like scabies or lice. If they're on my patient, I start feeling the bugs crawling all over me, too.

It would have been OK to describe the vent weaning goals to the surgeon or the house medical officer. At best, they could have acknowledged the weaning goals and still given you pain orders. Or, they could have called the intensivist and told him to manage his case appropriately and call you back. If you are charting that your patient is in pain, you called for orders and the MD hung up on you repeatedly, then you still need to call someone else for orders, I think. It's not good for the patient to let it go, and it wouldn't hold up in court. It's not the same as an MD listening to what you have to say, acknowledging the situation and saying the current orders are fine as is.

Could you have called the surgeon and asked for pain management orders? If not, you could ladder up the medical chain of command. Call the MD house officer, say I've called this MD twice, he's hung up on me, I need pain management for this pt. And then also talk to the intensivist the next time you see him.

Good for you! I switched from business to nursing at about your age as well, and am finishing up my 3rd year as a nurse now. Don't regret my decision for a second.

It seems odd to me that you admitted a septic pt without a sepsis protocol in place that would have included PRN pressors with parameters. (Also, no CP protocol?) In any case, I'm new to the ICU as well, but I would suggest a couple things for this change of shift admit: 1) be as assertive as you can when you get report from the ER. This pt was known to be septic. If your MDs do not come up to the ICU with their admits, then you need a central line placed in the ER, esp if you're going to have to start pressors in the middle of the night. Insist on a line before you accept the pt. (that way you can also get a CVP on your own if you have to call again in the middle of the night.) 2) Do quick assessments so you can get PRN orders before your attendings go off call. It doesn't matter that the BP hadn't changed much from the ER report. The pt is now yours and doesn't have appropriate orders in place. (A call to update the MD with current pt status and to ask for PRNs is also to CYA.) 3) You can always run questions like this by your lead/charge before you call. You are 3 months into this, it is expected that you ask questions. 4) Twenty minutes for an MD to call you back? I hope there's a space on your phone log to document that as well. (When an MD takes that long to call me back, I always document it in my nurses notes.) Your pt can crash out in that period of time.

How high can you put the HOB on a vented pt with a femoral art line?

anon456, I find it helps to write a "countdown" of fluids and put it on the bulletin board where the pt can see it. So, you start out by writing "1200 mls - June 8th 0700" at the beginning of the shift, discuss the goal/limit with the pt, and then subtract as you go. The pt always knows how much they have left, and they feel they have some control over how much and when they choose to use that 1200 ml.

Maybe she set off the bug bomb and inhaled it directly? She has depression - maybe some SI, too.

I was unaware there was a new test plan, so I looked it up! Here are the FAQs: https://www.ncsbn.org/2010_NCLEX_RN_TestPlan_FAQ.pdf