Tell me about nursing, and what you are expected to know/do

NightNerd, MSN, RN · Jul 27, 2016

-Average day: I work nights in med-psych; just stated actually. I'm sure others will agree that no work day looks exactly the same, but there are some tasks and routines that tend to show up quite often. Some of these are several med passes, collecting labs, notifying the doctor of patient needs and concerns, receiving and completing orders, and looooots of documenting. Other things get sprinted in depending on the patient's diagnosis, such as giving blood, foleys, tube feeds, suctioning/trach care, but in my experience those come and go.

-Pros and cons of med-psych: I really love it so far! I'm learning a lot, as this is a medical unit, but as someone who majored in psych before nursing, I also enjoy the mental health aspect of my patients' care. I also have fantastic coworkers. The downside so far is that I'm not a huge fan of conflict, and there are a lot of times when I have to be the bad guy, which ch obviously doesn't sit well with some of this population. I don't love the idea of having to restrain someone, but I imagine I'll get used to it once I've had practice doing it. And I don't like that certain nursing actions need a doctor's order; there is a little less autonomy in this specialty than in hospice, where I was before.

-Nurse's role: ASSESSMENT. Everything comes from assessment. So you do s lot of that, with a lot of communication to doctors and other disciplines about what you find. You deliver the treatment that is ordered, and then you assess the results of that, documenting everything meticulously. Lots of patient education, although the doctor is responsible for explaining tests and surgical procedures; you reinforce what they say. And advocate for your patient; if there's something they bed that isn't happening, or something happening that isn't in their best interests, you bring that to the doc's attention.

-What I wish I'd known: Hm. Can't think of much. I mean, there are still times at work when I'm like, "I need to refresh myself on this med/that disease/whatever," but that's part of learning. I think it's just important to be patient with yourself, keep the patient's safety as your priority, and ask questions and research as needed before doing things you're unsure about. And, it's important to remember, doctors are people, not gods. They have a lot of valuable education and experience and we do need them, but they don't get to treat you badly for it. Show respect for them and demand the same. (Most docs are pretty cool.)

-I have no experience with loan repayment programs.

-How to cope: Laughter, even at the most inappropriate things to laugh about. Venting to my coworkers, and listening to them. Educating myself so I'm as prepared as possible at work, and getting feedback so I can grow as a nurse and be proud of my efforts. Leaving work AT work, and having a full life outside of it that I feel good about and look forward to. Occasionally counseling, for those situations that I can't shake on my own. I haven't found too much about this to be really traumatic yet, to be honest, but we'll see how that changes.

-I think I mostly answered the doctor thing above.

Hope that helps!

roser13, ASN, RN · Jul 27, 2016

Nurses do not diagnose. Diagnosis is a function of the medical model, not the nursing model.

Here.I.Stand, BSN, RN · Jul 27, 2016

I'll preface by saying you'll probably get as many different answers as you get responses. Experiences can be very diverse.

1) I work in a SICU -- level 1 trauma/comprehensive stroke facility. No such thing as an average day. Example: once our census was down so some of us floated to other units. Charge nurses had to scramble a few hours later when a mass shooting happened. But much more common than the TV-worthy moments, we spend a lot of time keeping patients comfortable, clean, and hopefully free of infection and pressure ulcers.

2) RNs (assuming not advanced practice) do not have prescriptive authority; nor do we make medical diagnoses. We are however responsible for reporting all of our findings, with all of the information we have for the MD to make the appropriate dx/order the appropriate diagnostic tests.

I do make recommendations when I have them. For example, "patients BP is getting low -- 85/40, baseline is 130s/70s. Last hemoglobins 9.5, 8.8 and 7.5. Let's recheck the hemoglobin; do you have any other thoughts?" Or "I can't put my finger on it...her SpO2 is a bit lower but not terrible, her respiratory rate is a little fast but not terrible...but she just doesn't look right. I'm really not comfortable taking that ETT (breathing tube) out yet." (In that case, 30 minutes after I said that, she was turning purple with an O2 sat in the 50s. We ended up medically paralyzing her, she was so difficult to ventilate. Yeah glad I spoke up.)

We are accountable for our own practice, and can't use a "just following orders" excuse if we act I'm prudently.

3) not really...my education did a good job preparing me, I think.

Will finish later

Sour Lemon · Jul 27, 2016

-Is there a rivalry between doctors and nurses?

Sometimes they steal our mascot and then we sabotage their bonfire. But the patients get taken care of, eventually. We all laugh about it in the end.

Been there,done that, ASN, RN · Jul 27, 2016

The "average day " is brutal work. Nurses are not legally allowed to diagnose, but we are expected to inform the physician .. that there orders are incorrect.

I wish you luck... nursing is a beeyotch. I have been a nurse for 34 years.. looking back..l Would not have put myself through that.

vintagemother, BSN, CNA, LVN, RN · Jul 28, 2016

But I just have some questions of my own that kind of stick in my mind (and make me nervous about being a nurse).
Don't be nervous. Choose to exude confidence!
-First off, I would love to hear about what your average day is like. And if you have a specialty, what are the pros and cons of your specialty?
I've only worked as an LVN/PN. But still
as a nurse, and often a charge nurse with me in charge of the facility, alone.
-Second, how much of a role do nurses play in diagnosing a patient?
We, nurses, do not assign medical dx. Rather, we utilize a nursing dx in order to provide holistic care geared toward the pts individual needs.
Do they need to get approval from doctors before beginning treatment or treating a patient?
In some settings, you need an MDs approval to do almost anything. In other settings, you will have orders you can implement to meet the pts needs. In other settings, you have to call the MD to explain what your are observing and request orders that your pt needs.
Depending on your specialty how does this process work at your job/what's the protocol for treating/diagnosing a patient?
See above.
-Looking back on your education and career path, is there anything you wish you would have known, or any advice you wish you would have listened to? Or anything along those lines...
Play nice in the sand box. Be a team player. Use the chain of command/defer to your supervisor.,
-Have you ever taken part in a loan repayment program (nurse corps/VA/or something else)? How did that go? Any pros/cons?
No experience.
-How do you keep your emotions and personal health (mental/physical) in balance?
It's been tough. A challenge. Working out has helped me. I also am under the care of a doctor and have been prescribed meds and counseling.
What are your coping methods? Have you ever had to deal with a difficult or traumatic situation at work that threw you off your game? How did you deal with it?
Laughter is the best medicine, for me.
-Is there a rivalry between doctors and nurses? My mom works at a hospital, and she says that some doctors are arrogant and demeaning to the nurses and support staff, and others aren't. But if you've been in that situation how did you deal with it?
I have to say, most of the MDs I've worked with want to know if you know your stuff. If you do, they'll trust you. My MDs have been just fine, if not awesome.
.

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Here.I.Stand, BSN, RN · Jul 28, 2016

"I'm prudently" in my prior post should read "Imprudently." Dang autocorrect.

Here.I.Stand, BSN, RN · Jul 28, 2016

-How do you keep your emotions and personal health (mental/physical) in balance? What are your coping methods?

Prayer/Bible study, laughter, exercise (I do Insanity and like to hike. Thinking about taking up climbing. I don't like the gym at all...too noisy.) Doing fun stuff with my family. Hug my babies. Indulge in a homemade latte or frappe -- I can make them tastier AND lower calorie than the big box coffee places do.

Have you ever had to deal with a difficult or traumatic situation at work that threw you off your game? How did you deal with it?

Lots of them. While at work, I'm never thrown off my game. Occasionally I do blink back tears, but I keep focused like a laser beam. How it does affect me is profound physical fatigue after I get home. I do the above things... but if it's really bad, I'm honest with my husband that I had a rough shift, and can he get breakfast in the a.m. so I can sleep in (I work 3-11 p.m.) Maybe 3x in my career, it's taken me a good week to feel "normal."

I'm big on self-care for this reason.

Julius Seizure · Jul 29, 2016

(This is long. Sorry not sorry!)

-First off, I would love to hear about what your average day is like. And if you have a specialty, what are the pros and cons of your specialty?

Average day:

-7a-7p shift in a pediatric ICU. We have 1-2 patients per nurse. Shift report can last up till 730 at times, and then if its a new patient for me, I usually review the chart for about 20 minutes if I have the time. If I had the patient the day before, then I just have the previous 12 hours to review.

-Assessments are every 1-2 hours. At the 8am assessment, I also do safety checks to make sure that all my emergency equipment is set up properly in the room and that my alarm limits are set correctly. I also given any meds that are due during this time. I leave the computer chart open in the room as I assess/give treatments/meds and try to chart as I go, when possible, but sometimes it can't be done. Every 1-2 hours, I/Os, vitals, IV checks, are also recorded.

-Sometime between 9 and 12 are rounds, depending on if the medical team starts on your side of the unit or the other end, and how fast they move. Sometimes rounds get interrupted for emergencies and that makes everything late, too. Its a teaching hospital, and rounds usually includes 1-2 fellows/NPs, an attending MD, a dietitian, a pharmacist, and the bedside RN. Respiratory therapy tries to attend, but sometimes they just don't have time to do it all. We don't use residents in my ICU, but some other the other ICUs do. During rounds, I give a brief update on the patients current status (pain status, sedation issues, any IV access concerns, any new changes in the past few hours, or anything else that I think is pertinent.) Then the fellow or NP does their bit (patients history, their assessment from that morning, and their plan of care). After the attending agrees or gives input, orders are written, and generally the attending asks the bedside nurse if they have any other concerns they would like to address. (I love our attendings.)

-After rounds, I prioritize which orders should be carried out first and which can wait. I make any phone calls needed to coordinate with other departments for tests or to get supplies that I need. I start to talk with my neighboring nurses about who will cover whom for lunch and when we can go. We are a good team here and everyone almost always gets lunch, even if it might be late some days.

-I keep doing q1-2 hour assessments, while also carrying out the new orders, drawing any scheduled labs (no phlebotomy here), giving scheduled meds/tube feedings, and addressing and pain or sedation issues. Throughout the day, I am constantly re-prioritizing and re-evaluating what needs to be happening for my patients.

-If any changes happen or I have any concerns, I call the NP or fellow to address them. Rarely will I need to speak with the attending, but if I don't feel satisfied with the answers that I am getting from the NP/Fellow, I can always go straight to the attending.

-Most patients get bathed and weighed on night shift, but our most critical and unstable patients are done during the day. We also have procedures like central IV line placements, intubations, extubations, chest tube placements. Often these are emergent. We are a surgical unit so we also have 2-4 OR cases most days and everyone pitches in to help their neighbor when the case comes out to the room.

-Night shift comes in and shift report happens at 7pm. Whew! Time to go home, sleep, and come back to do it all again tomorrow!

-Pros: PICU can be very rewarding when you see a kid get better after an acute illness. Kids are resilient and its amazing how they can heal. Also, I prefer nit-picking over 1-2 patients than trying to wrangle 5-8 on the med-surg floor!

-Cons: Kids die. It sucks. But its also an honor and a really special thing to be there for the beginning and endings of life, and pediatrics is no exception. Families can be hard. You have some fabulous families, but a lot of frustrating ones - either complainers, or know-it-alls, or dismissive of the nurse, or just plain absent and its frustrating to see their kids who are hurting from it.

-Overall: There are a lot of hard days. But you will never have to wonder if you made a difference or not - you did.

-Do nurses need to get approval from doctors before beginning treatment or treating a patient?

For things that fall under the medical plan of care, yes. For nursing plan stuff, no. But nursing plan stuff is like....fall precautions and measures to avoid infection. Its kind of standard-of-care. For medical treatments, the doctor has the final word on that, but in my unit, the decision making process includes the bedside nurses opinions. I think teaching hospitals are often better at that. Also, small things like.....if my tube fed patient starts not tolerating feeds (vomiting, or distended abdomen, or bloody stool, etc), i will stop the feeds before contacting the MD. Only because I am pretty sure thats what they will want, and its easy to reverse if they dont. And its the prudent thing to do. But I always, always contact the MD - why? Not because I don't know what to do (I may or may not). I contact them because its a change in the patients condition.

-Have you ever taken part in a loan repayment program (nurse corps/VA/or something else)? How did that go? Any pros/cons?

No, but I probably wouldn't do the nurse corp - thats the loan forgiveness thing right? I think the way that works is that your loans are forgiven after working in a qualifying place for a certain amount of time - but the forgiveness doesnt kick in until you make TEN YEARS of on time payments! By then you should have paid a lot, if not most, of your loan back anyway. Its not worth it to me. The VA can be a sweet deal though - I have a friend that worked for them for several years....they sent her to CRNA school for free, AND paid her an RN salary while she went to school for 3 years. In return, she just had to commit to work for them as a CRNA for 3 years, and they held a spot open for her employment (yay no job hunt).

Julius Seizure · Jul 29, 2016

If I had to summarize a bedside nurses role (off the top of my head):

#1- To assess and monitor the patients condition and response to treatment, and to alert the medical team when intervention or changes in that treatment may be warranted.

#2- As part of an interdisciplinary team, to formulate and carry out a plan that helps restore the patient to their optimal level of wellness. (OMG I SHOULD WRITE A NURSING THEORY BOOK.)

ottersloveoysters · Jul 29, 2016

I would strongly suggest shadowing a nurse who works in an area you find interesting. As others have mentioned an outpatient oncology nurse will have a vastly different day from a neuro ICU nurse or a nurse who works in the clinic of a homeless shelter. I work with terminally ill patients and regularly have other nurses say to me, "I could never do your job!"