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

Two more organizations recruiting: http://www.nurseswithpurpose.org/sitepages/pid62.php To apply to work on the USNS Comfort ship (also with a good list of vaccinations to prepare): http://www2.recruitingcenter.net/clients/ProjectHope/publicjobs/controller.cfm?jbaction=JobProfile&Job_Id=10316&esid=az

L8RNN You're right, my personal experience with people with this disorder is very limited. But I will admit my bias and say that my view of the disorder is very colored by my experience. In any case, I didn't say that people with the disorder couldn't be nurses. I said I was concerned, and that "I guess it would depend on the degree of severity [and I should have said how it manifests] and also what kind of nursing they want to do." There are lots of opportunities in healthcare. Nursing is well-known, but some other important roles are not. For someone just beginning to enter the field, those roles deserve consideration too, especially in this economy where so many nurses are having a hard time finding jobs.

I did home health as an LVN for a while and had a patient who was highly functioning and had Asbergers. She was extremely unempathetic to her caregivers. She was very intelligent in a few areas, but after being with her for such a long time, it was more like talking with a 12 year old. I cannot imagine her being responsible for anyone else. The way she talked about the sudden death of her dog was almost inhuman. I worked in an urgent care after doing home health. I had plenty of anxious patients there, but the visits were short. Now I work on a tele floor and I am amazed at how many patients we have with underlying psych conditions. Managing their care for 12 hours has been one of my biggest challenges as a new RN. I am concerned about the two students above with Asbergers who want to be RNs. I guess it would depend on the degree of severity and also what kind of nursing they want to do. Even in the ER where in theory the visits should be short, nurses often have very difficult patients they have to take care of for hours and hours because there are no psych or medical beds available. There are other positions in healthcare that do not require as much therapeutic use of self as an RN does. Xray techs, ultrasound techs, dietary, speech, RT, PT, OT. They all have patient contact but for much shorter periods of time. I would encourage your students to consider these as well.

I peeked in this thread because I had a patient yesterday who is similar to yours. I find the non-compliant dialysis patients to be some of the most challenging on our floor. A couple things you may want to ask yourself: -what's going on with their skin? Why? -you have the fluid volume excess ND above. Is it a dialysis day? What's going on with their BP before and after dialysis? Does it make sense? -how is their diet managed in the hospital? Any supplements with meals? Why? Hope this helps. :)

Also, if you're giving blood, new pinky-red urine can be a sign of an acute hemolytic reaction. Stop the blood, call the blood bank and the MD.

I was an LVN for a couple years, so some things aren't new. For me, it's definitely time management. Also, you have to meet a lot of people in the hospital environment to get your job done. Sometimes, the MDs are in and out so quick, it's hard to catch them. And when it's their day off or they're on vacation, the MD covering for them will say, "anything I need to know?" Sometimes I wonder if they're really filled in on the details of the case. Interacting with the MDs is still tricky for me.

I am totally in the same boat. 6 weeks of orientation, have spent 2.5 weeks on my own now. People say I look calm on the outside, but I am 8/10 stressed out on the inside. I am on days, there are heavy admits and discharges on this tele floor. I am slow to discharge, just trying to pass meds and then it seems like something always happens (crashing pts, new admit orders, prns, pts leaving for tests) that I can't get to my discharge. I get there 30 mins early to prep, have not been able to take 15 min breaks and have left late every day except for two. The other nurses are nice, but when I say I'm stressed out, they say, "really?" They sympathize, but I think they've forgotten what it's like to be new. I had 3 jobs as an LVN. This is my first hospital job. It's just OK. The 6 weeks of orientation were just barely enough to feel comfortable. There's still so much that I don't know how to do or watch out for. I usually go home and think of things that I've forgotten to chart.

I was one of the lucky ones to get a job before graduation. After I applied for my job, I emailed a couple people who worked for the same hospital to see if they knew any of the hiring managers. One of the people I emailed was a former teacher at my LVN school I attended 2-3 years ago. He didn't email me back, but I just found out that he had forwarded my email to the manager who later hired me. Even in big hospitals it seems like everybody knows everybody. You just never know...

I think it's great that you are thinking about this issue and recognizing that it is something you need to work on. Being the kind of nurse you would want for yourself goes hand in hand with being the kind of person you would like to be. You will encounter different kinds of patients in different areas of nursing. I've been surprised of how much domestic violence I come across in my work. I also usually have one patient going through drug or ETOH detox, and that is not a fun time. These patients are leading very different lives than mine. However, my contacts with my patients are pretty brief and I'm working so fast that I don't have much of a chance to get involved in the details of their lives. Not like when I was doing home health and I was with the same patient for 12 straight hours. If this is your first nursing job and you don't like it, you could move to an area later like the operating room or a procedural area.

When I worked nights, I would pop some benadryl as part of my going-to-bed routine if I had to work the next night. Worked pretty well, and I always felt rested. Also, I never stopped to do errands on the way home. Always home, showered, and straight to bed.