Rural ICU nurse - need advice/validation

Posted
by Lynden74 Lynden74, BSN, RN (New) New

Specializes in ICU. Has 16 years experience.

I've been a nurse in a 25-bed critical access hospital for 15 years (2nd career).  Prior to this past year I have have worked med-surg, L&D, infusion/chemo.  My orientation to our 5-bed ICU was very inconsistent and choppy as I was still filling in in my other position while they filled it.  During my orientation the ICU was often actually empty - or we had med-surg patients.  I had VERY minimal hands-on ICU orientation - most was online classes and EKG monitoring classes.  

From the beginning I expressed my concern of never seeing anything critical during and then having to manage a vent patient with drips independently.  I suggested the orientation process be continued - and call me in when we have a vent patient, but I continually felt unheard.  We have since had a major change in nursing administration - and currently have no nursing admin with critical care background.  Most of what I now feel comfortable with is managing COVID patients on heated high flow or bipap.  I still don't feel fully confident in reading cardiac rhythms (we monitor all telemetry for the med-surg unit also) - and often when I ask the co-worker I'm with about a rhythm they cannot answer my questions.  

We've recently been seeing COVID patients needing to be intubated.  I cared for one a couple days prior to transfer to higher level of care.  It was very unnerving, but I told myself to just start by making sure everything I was already familiar with was A-OK.  The 2nd day I had a terrifying incident I won't go into details on (resolved quickly, but could have easily been a sentinel event) - left me a bit traumatized.

This past weekend we had another patient on a vent - I was so tired from lack of sleep I didn't feel safe to manage it the first day since it is such unfamiliar territory.  I agreed to take the other 4 patients if the other nurse would manage the vent.  The nurse managed the sedation rather poorly and I was a bit traumatized again - not fully recognizing until conversations the next day that it was the nurse poorly managing and not the patient status.  I planned to take the patient the next day as a night shift nurse agreed to stay over and give me some assistance - however I woke at 2am in sheer anticipation anxiety and could not calm myself to fall back asleep.   I resolved in the middle of the night I could no longer do this job.  The brain fog and anxiety paralyzes me and makes me feel so unsafe.

I'm told over and over "but you're a great nurse" - and I feel no one relates to or understands my fears.  I am probably much more sensitive and feel things much stronger than most of my peers - so am affected more and therefore people cannot relate.  I do believe with better management of my anxiety (which I have been working hard at) and spending more time/$ on classes I can possibly get there.  I'm a harsh critic of myself and have always placed extremely high expectations (also am working on this).  I've worked so much extra this past year with COVID finally hitting our hospital hard and lack of staff - I've been too exhausted on days off to try to learn more.

What I'm looking for here is validation, I guess.  How many of you were expected to manage a vent patient without having had a preceptor work with you first?  Or am I overreacting?

Or is it time for me to move on?  Am I not cut out for critical care because of my strong anxiety reactions?  I feel sad and defeated because I love my coworkers, love the focused care of ICU and the more depth of knowledge required.  I also feel such a strong responsibility to my small community - nurses are leaving everywhere and I don't want to be the next one.  I'm considering talking to my manager about going back to med-surg, but I know I won't last very long there.

I've posted before about some of my concerns here.  I've reached out to a critical care nurse administrator I know in a sister hospital and am waiting for some feedback from her also.  

Thanks for listening!

Nursetom1963

Nursetom1963, BSN

Specializes in ICU. Has 31 years experience. 68 Posts

OK, I'll reply, what do you mean by "managing" a vented patient?  Do you adjust the vent, and understand the settings, or do you have an RT to deal with that?  You sound similar to me in my ICU; I have vented patients, but the RT deals with the vent.  I understand the settings, and the ABG, but I don't have to deal with it.  I manage the sedation; you should have a sedation scale target you achieve and chart something like Glascow Coma Scale; eye, motor, verbal; but on a practical sense I we keep them sedated enough so they don't reach up and self-extubate. Other than that, it's watch vitals and deal with them; Bp up, do an anti-hypertensive, down, probably a bolus or a pressor (with orders of course).  You should have protocols for your drips; to tell you how to titrate. Shift side to side, oral care, peri/incontinence care, tube feeding (HOB up) meds.   I think these patients are easier to care for than M/S patients.  If you're getting anxious, I always go back to ABC; you have an airway (they're intubated) they are breathing (on a vent, they can't stop if they want to) only thing left is do I have a pulse/perfusing rhythm?  Everything else is gravy.  Monitor, ask "why"? and adjust.  Is there a MO you can ask about rhythms?  Find and take a rhythm class or book, and a Critical Care course.  Look up the drips and how they work and what you expect to see and when.  

Lynden74

Lynden74, BSN, RN

Specializes in ICU. Has 16 years experience. 10 Posts

Thank you, Nursetom 1963, for your response.  I have taken a rhythm's course and certainly can easily identify major changes (and of course lethal rhythms).  I've learned that I'm just overly concerned compared to the other nurses when it comes to rhythms and am learning to relax more.  Unless cardiolgy is consulted no providers are reviewing them so I felt a lot of responsibility - the hospitalists just rely on the nursing staff to alert them of concerns/changes.  I actually had to look up "MO"!  We have one hospitalist on who is in house for 4-6 hours/day depending on what is going on - so relying on them for questions isn't always an option.

And as far as "managing" a vent patient - yes we have RT 24/7 when we have a patient on a vent, so I'm responsible for the rest.  I've found a couple great online resources - one per a recommendation I received here on allnurses so that is helping.

I think overall it comes down to managing my anxiety - and having a little more faith that if I'm being diligent and doing my best - I cannot control all the outcomes.  I'm doing all the right things - just want someone to reassure me/answer questions 'in the moment' and that's where I feel a lacking - just a little hand-holding would have helped, I guess!!  I also realized I rely so much on interaction with awake patient's as a part of my assessment (esp Neuro) that it's just a learning/comfort curve.  We don't have much in the way of protocols - with our new DON that may finally change.

Also, too often there seems to be no urgency to get central line access for these patients, even with poor options for IVs.  Radiology will not place PICCs at the bedside, nor if they're on anticoagulants (who's not, right?) - so we have to wait to hold anticoags for the surgeon to place a line at the bedside.  We recently lost one of our two IVs and it was a mess.  I will have to start putting in more incident reports perhaps for this to start being heard.

Lastly - it has been especially difficult I guess with COVID because I cannot always see the patient as the doors have to remain closed.  Unless I'm standing at the door looking over the privacy glass area.  Sigh... Once again... Have to learn to relax...

SuperSaltyNurse

SuperSaltyNurse

Specializes in Rural ICU RN & Educator. Has 19 years experience. 1 Post

Hello Lynden74!

     I feel you working small ICU! I currently work in a four-bed ICU with intermittently ventilated patients. Before COVID 19, it could be six months between vents. I had ten years of extensive hospital ICU experience before moving to the rural setting, so I am slightly different. However, I help orient new ICU nurses. Here are a few things we do with new ICU RNs.

1.) Off the floor time with RT to acclimate to VENTS, HFNC, BIPAP, even oximizer, and NC devices.

2.) Does your site have access to a Tele-ICU program? We work actively with Tele-ICU to help manage our patients locally. 

3.) AACN Essentials to Critical Care, another class but a good one.

4.) Nicole Kupchik Progressive Critical Care Nurse (PCCN) certification course (another class, but an excellent review of all systems). She also offers a Critical Care Certified Nure (CCRN). The PCCN seems more geared towards small ICUs.

5.) Nicole Kupchik Mechanical Ventilation Online Course ( I have not done this one, but I am thinking about it.)

This is a learning curve. Kind of a trial by fire. It is doa le. Remember to give yourself grace. 

6.) Review resources for sedation: Propofol, Versed, Fentanyl, Precedex. We use Micromedex. 

7.) Your Charge Nurse, are they ICU trained? We utilize Charge Nurses for resources. Our core staffing is Charge + 2 ICU RNs regardless of ICU census.

       Good Luck to you!,

                     

 

Lynden74

Lynden74, BSN, RN

Specializes in ICU. Has 16 years experience. 10 Posts

Thank you, SuperSaltyNurse, for your reply --- and validation!!  Someone else mentioned Nicole Kupchik and I have utilized some of her free resources so far and intend to take her vent course.  I'm also considering the AACN course, but am trying to first decide if I'm going to stay before I invest the money.  The sheer exhaustion of working 4-5 12-hour shifts/week with no breaks during the COVID season has left me completely wilted.  It has been hard on my days off to find the capacity to learn more.

We do not have access to a Tele-ICU program, but I'm going to mention this to management.  I'm now familiar with those 4 medications you mentioned, but it's been several months since I've had a vented patient (actually since I've had an actual ICU patient as we often have med-surg overflow).

During the week our supervisors (we do not have charge nurses) do not have critical care background (med-surg/OB background).  Sometimes I will be the only ICU nurse working - that means I'm the ONLY person in the unit - no ward clerk, no CNA, no other nurse - but a OB-trained supervisor that checks in here and there (and has taken ALS).  Recently I had someone on a cardizem drip, was alone and the ER was busy - I had no one to discuss a questionable change in their cardiac rhythm.  I'm also responsible for monitoring all of the hospital's telemetry (which obviously goes unmonitored when I'm in rooms doing assessments, bathing, etc - a whole other issue).

I GREATLY appreciate you mentioned your core staffing as we have a meeting next week to express staffing concerns and I don't know what is acceptable quite honestly.  National standards may say 1:2 for RN:patient ratio in ICU, however, in a large ICU there are also techs, unit clerks, pharmacists, etc. - not to mention other nurses - available to help.

Many want to say we are not a "real ICU", but that is why it is so frightening - we have the potential to become one at the drop of a hat with no resources.  If I have a patient who suddenly needs to be intubated and needs lines - I'm arranging everything, including mixing drips, etc. this doesn't not always happen during the 7a-3p hours that pharmacy is in house.

Thank you again!