Clarysage ADN, BSN

Rosie_one, thank your for that answer. I am not a new nurse, but I am new to neuro. I am starting a position in neuroscience ccu in just under 2 months. I am much more familiar with cardio, and am reading all I can about neuro before I start. Just from treating so many stroke patients and TBI's I am familiar with some of the differences. But working in LTAC, I see the results on the other end. Thank you for the reminder of the Monroe-Kellie Hypothesis (haven't thought about that since clinicals many years ago), and the importance of hourly neuro checks. Just from my time shadowing, I am able to appreciate the importance.

I just accepted a position in a Neuroscience CCU, and start in just under 2 months. In that time I would like to brush up on my med knowledge, procedures since many are done bedside, tPA, etc. Are there any books that you found helpful in your experience? I found this one on Amazon (Clinical Practice of Neurological & Neurosurgical Nursing Seventh Edition by Joanne Hickey PhD RN ACNP-BC CNRN F), any input would be helpful. I am a nurse with 7 years experience in long term acute care. You could equate the experience to step-down or progressive care. Very familiar with vents, stokes after the acute phase, and cardiac drips, but not as familiar with clinical significance of ICP/EVD's, neuro meds, etc. It is one thing to get that history in report, another to experience it on the front end. I at least got to spend a day shadowing, and my nurse had a patient who was on multiple drips, had 2 EVD's, and a Codman just for monitoring. Amazing, fascinating work being performed by these nurses. Thank you!

Hi. I haven't read all the responses yet, so this may have been stated already. On my unit we assign a code team at the beginning of the shift, and announce it during our morning shift huddle. We run our own codes and RRT's. Only an anesthesiologist will attend if the patient does not already have an advanced airway. If you are on the code team, you are obligated to that situation. Yes, more people than needed initially arrive. We do this only to cover code team members who may not yet have arrived. Once they have, the room consists of (generally) Leader, Monitor, Meds, 2 for CPR, Recorder, and a respiratory therapist. If you're not on that team, you are expected to be covering the floor. Still, with 4-5 nurses in the room, that is about 16-20 patients who need covered by staff who already have a 3-5 patient assignment. No matter what, someone is going to be waiting. It is up to you to be able to prioritize care. Cardiac and pain meds before colace. Be professional, apologize for the delay, leave the room courteously when you are finished. If you truly were where you needed to be, your manager will know that. If you were at all disrespectful or sarcastic-and I am not assuming you were-then you need to own that. You will never make everyone happy, all the time. Let it slide. Just an anecdote and show of empathy for you-I was once in a code where the patient was also hemorrhaging everywhere, and we were running in blood products and fluid as fast as we could. The lady across the hall was so agitated that we would not stop what we were doing to come and give her an update on her husband (with whom she roomed, and had only left him for about 2 hours to grab a meal), that she actually called into the room to distract the physician, and asked him when he would "finally be done in there." Well, I watched the physician, the kindest man I have known, tell the woman where she should shove it, and threatened to have security haul her away if she didn't leave immediately! If we never became nurses, we would have missed out on all the best stories!

hherrn, I am good but not great at IV sticks and blood draws. Since I work LTAC, our patients have been getting stuck daily, some several times per day, for months at a time. Many of them are elderly and/or obese, and A/V fistula in one arm, so we can't use that arm (per our policy). The more of them I do, the better I get. But I have definitely come across problematic rolling veins. Even when anchored, they still roll somehow out of reach. This is pretty common in elderly people who lack the sq tissue and muscle tone to hold everything in place. To top it off, they are usually "ropey" as well. My technique is pretty simple, and I would say I have about 85% success rate. I spend a lot of time looking for the right vein. I massage, change position, use heat, and sans tourniquet if necessary. I am not afraid to go grab another RN who I know to be good and ask for assistance-either a confirmation of where I want to go, or just to have someone there to hold the arm if it will be an awkward position. Lastly, if I can tell that the veins roll more than usual, or if the patient know this, I try to go in from the side of the vein. It sounds counter-intuitive, like it would just roll further, but I have better luck with this method than I do approaching from the top. (and, of course, always anchor)

I hope for your sake that you made the right call, and only you will know if you did. If you didn't, it's not too late. While you may have missed a residency program, you may still be able to find an employer who has a nurse internship. It's a little different from a residency. My employer has an intern program where they hire app 5 new grads (or old grads who have been out of it for awhile) and take them through a program that is more like your nursing school clinicals. Well, not just like it-the intern program is supportive and nurturing whereas my clinicals were a massive weed-out sink or swim program. But you get the idea. And if after that 90 days of being paired with the educator and preceptors, you feel you need a little more time, then it is offered. What you experienced may have actually been more positive than you realize. You should be scared! This is life and death, and not many people can literally say that about their work. If I were your preceptor, I would have probably noticed that you had a case of the "yips" but I would have been so happy to have a new grad who asked a lot of questions. The new grads who scare me are those who never have a question. After a year or two on the floor, you'll find yourself feeling like it is all starting to click. You'll still have that nervous energy, but it will be more of a voice in your head telling you that there is something about your patient that just doesn't feel or look right, and that nervous energy or adrenaline is what will sharpen your mind so that you can jump into action. Don't be too hard on yourself. Every nurse learns in a different way, at a different pace, and there is no single area that is good for everyone. No matter where you find yourself, whether it is giving your old unit another try, or something totally new, just give yourself the chance to learn, and never stop asking questions. And if staff is not willing to nurture and support you, then keep searching. Best of luck to you!

I am sorry that happened to you. Pretty much any nurse with experience has been there before. I know I have. What I have realized is that, while unfair, it's not always as it seems. (I have a reputation for being the calm, fair one-sorry ;-) I don't want to devalue your experience). Sometimes when doctors act like this it is because they are mad at themselves and take it out on you. Unfair, but when that's the case they tend to follow up with a softer touch. Other times, they are so used to their own personal staff knowing what they want, when they want it, they don't realize they are being unclear. You did the right thing by reminding him you are not involved in his specialty. In other cases-the one I experience most at work-some people just wear their hearts on their sleeve. Our regular nephrologist has frequent tantrums, although he never directs it at the nurse. We are just the unfortunate ones to absorb his venting. Many nurses take him very personally. I have learned to really appreciate this doctor, and know the routine. "Well, that wasn't ordered, doc, but tell me what you need and I'll take care of it for you.."-that turns him into an instant, apologetic softie. But sometimes, rarely, they are just Neanderthals. I find that younger and newer doctors can be much easier to deal with, as many of them rely on the observations and judgement of an experienced nurse. They tend to treat us as we are-a different specialty, not an inferior or subordinate. They are almost always willing to teach, or let you in on their thought processes, as well as hear yours. My guess is this is where your BF is, and he probably despises being compared to the more primitive variety. If he is a new doc, chances are the urologist would have been almost as nasty to him as he was to you. Doctors who treat nurses poorly usually have that reputation with everyone. Chances are good that other doctors know this about him, don't like it, but are too professional to openly reprimand a colleague. Keep your chin up! And keep a "for emergency, break glass" arsenal of come-backs locked away for when you need them the most.

I am curious. Twenty two to 44 residents in a med pass? Are you confusing LTAC with LTC? (Or did the original poster possible mean LTC?) I work LTAC, which is long term acute care, and very different from long term care. I don't believe there is an LTAC with that ratio, but it could be possible in LTC. LTAC patients are mostly step-down ICU, usually either on a ventilator, or some type of gtt, and very sick. Just curious.

I have experience with Select. It was my first RN job out of school, 5+ yrs ago. I went through an orientation period with a preceptor, I am sure that is what they are referring to. You will not be practicing alone. LTAC is hard work! In my location we have day shift patient ratios of up to 5:1, although this is not the ideal. Depending on acuity, you may only have 2-3 patients. These patients are sick. They have been released from the ICU, too sick to go to a regular med surg/tele floor, but no longer qualify for ICU. This is insurance-driven, so sometimes you will get a patient from the ICU who needs that level of care, but the insurance won't let them stay. So, you will get so much experience that you may not have gotten anywhere else outside of the ICU-ventilators, trachs and airways, dialysis, extensive wounds, cardiac drips, blood transfusions...you will always be learning something new. You will develop critical thinking skills and time management skills. You will work long, hard hours (it's nursing, after all ;-), but you will learn so much! And if you give it a couple of years, the time it takes any new nurse to become proficient, you will have a knowledge base that will prepare you for anything. Best of luck in whatever you do!