Last night was a *** show and I'm looking for pointers. New grad; licensed for 9 months and 3 months into first real hospital job (step down ICU). I'm also 60 years old (and I wonder if that has anything to do with it).
Our unit does V/S q.4, focused q.4, HTT at start of shift (12 hours). NAs do not do any VS other than 2000.
I had one patient who had intractable pain - narcs every hour, allergic to everything so had to manage her hives/itching reaction to the narcs with benadryl and other options. she had 3 drains (duodenal, new nonfunctioning jtube, something else and foley). POD2. PSH of several spinal surgeries and her body looked like some congenital stuff (never got a chance to check her history so honestly no clue). she had TPN, lipids, 3 different antibiotics running into a 3-lumen PICC that, by the end of the shift, had only 2 working lumens. thankfully did not have to reposition her. She had an NG and was unable to swallow (not sure of the HX there) so for PO meds I would put them through the NG and turn off suction for an hour and hope they were absorbed. she had BG checks q.4 in addition to pretty much hourly meds/pain meds. Contact precautions and NAs never entered the room except for 2000 V/S.
patient 2 had only an ileostomy with crappy lungs. day before I had asked day shift to request CXR and RT/Pulm consult because her lungs sounded super coorifice, she had a green sputum and productive cough. intractable pain and meds q.2 hours (oxy and dilaudid) in addition to her other meds. TPN with 3 rate changes during the night. PICC line with 2 good lumens. I think she had abx - don't remember. BG checks q.4 hours. NA did one of the checks.
patient 3: New admit from ER for CHF exacerbation, only had her for 8 hours of the shift. non-english speaking but had daughter to translate. She was my easiest once I spent about an hour doing the admit, setup, V/S (only twice as she was there only 8 hours), but then her BP started dumping (high 80s/40s) and I had to spend a good 30-60 minutes focused on that.
patient 4: POD2 with wound VAC to RLE, 3 new surgical sites, q.2 hour pulse checks, abx, pain well controlled, little forgetful and confused but stable. this was my 2nd day with him and I had asked day shift the day before for lasix because his LEs were so tight, peeling and discolored I was worried for compartment syndrome (not seriously but dayum they looked awful). he was on heparin and bridging to coumadin so I was chasing his labs and titrating his heparin also. by end of shift we were down to +3 pitting edema (huge improvement from rock hard skin) on surgery leg and +2 in nonsurgical. during the q.2 hour pulse checks (I missed one of them during the night) I had to reposition him and get the surgical leg elevated.
patient 5: bariatric POD1 with N/V unable to hold down water, pain, EtOH and drug abuse HX (I found from day shift during report), but really a very stable patient. I was in there more than q.4 hours as I was staggering her meds so she could try to keep some of them down.
So, hour one (20-21) I did HTT on 3 patients and got meds up to 2100 passed as I suspected I was going to get another patient and I wanted to be ready if/when that happened. Found out about 15 minutes before tranfer I was getting the ED xfer so I was glad I had planned for another patient.
Hour 21-22 passing meds, addressing pain on pax 1 and 2, charting exceptions to HTT, adjusting TPN and replacing all tubing (expired). chlorhexidine baths on the PICC lines. Chart 2 HTTs fully. Check everyone's labs and make sure nothing was crazy. Give insulin like candy.
hour 22-23 pretty much dedicated to new admit.
hour 23 I got 5th patient. HTT on them and keep running all the meds
hours 24-8 I'm bouncing from patient to patient. We had 2 rapids on the unit and everyone was pretty busy. Shift ended at 0730 but day shift as a whole said it seemed like many from night shift were trashed at report. I didn't start charting until 0830 as I was still responding to the uncontrolled pain patients and making TPN changes and trying to give report (we do bedside). There were 6 of us charting from 8-9 and 2 of us from 8-10.
So, new grad, I know I'm lousy with time management but I do try to cluster stuff and anticipate *** coming up (I will dump heparin and maintenance fluids in the rooms (after say 0100 or so) so if the alarm goes off and an RN sees it they might hang the new fluid. I keep my tubing labeled and know when it needs to be changed (all TPN, lipids and abx tubing was changed so I make sure I have that *** before I leave the med room). We ran out of 10mL flushes about 5 am so I was chasing my *** on that for the PICC line patients.
So, pointers on how I could have structured the night better?
Hats off to you for surviving this night! Five is too many patients for step-down especially when they all sound quite ill. It sounds like you have done many things within your power to help the situation. If these are the unit expectations to manage 5 patients, I might look elsewhere if things don't change.
Specializes in Maternal Newborn and Denials Management.
That's the kind of night you pray everybody just lives until morning and pray you don't make a mistake. Many nights on Oncology were crazy like this and I would be at the desk charting for 2 hours afterward. This is from a 30 year nurse. The last 10 years of my bedside nursing career was in mother/baby and even though the patient were not "sick" there would be nights just as crazy with 4 fresh C/S mothers and newborn couplets to care for. Sometimes I was the only RN with two LPNs who were wonderful but I had to handle all of their med pushes and had charge duties in addition to my own patients. Frankly I am glad I left the bedside 10 years ago for audit and denials work. I still have nightmares where I am working as a floor nurse and "forgetting" to take care of a patient for an entire shift. This never actually happened to me but it was one of my biggest fears as a nurse.
I still have nightmares where I am working as a floor nurse and "forgetting" to take care of a patient for an entire shift. This never actually happened to me but it was one of my biggest fears as a nurse.
I have dreams sometimes that I get to 0700 and realize I forgot to give a single medication all night ?
Last night was a *** show and I'm looking for pointers. New grad; licensed for 9 months and 3 months into first real hospital job (step down ICU). I'm also 60 years old (and I wonder if that has anything to do with it).
Our unit does V/S q.4, focused q.4, HTT at start of shift (12 hours). NAs do not do any VS other than 2000.
I had one patient who had intractable pain - narcs every hour, allergic to everything so had to manage her hives/itching reaction to the narcs with benadryl and other options. she had 3 drains (duodenal, new nonfunctioning jtube, something else and foley). POD2. PSH of several spinal surgeries and her body looked like some congenital stuff (never got a chance to check her history so honestly no clue). she had TPN, lipids, 3 different antibiotics running into a 3-lumen PICC that, by the end of the shift, had only 2 working lumens. thankfully did not have to reposition her. She had an NG and was unable to swallow (not sure of the HX there) so for PO meds I would put them through the NG and turn off suction for an hour and hope they were absorbed. she had BG checks q.4 in addition to pretty much hourly meds/pain meds. Contact precautions and NAs never entered the room except for 2000 V/S.
patient 2 had only an ileostomy with crappy lungs. day before I had asked day shift to request CXR and RT/Pulm consult because her lungs sounded super coorifice, she had a green sputum and productive cough. intractable pain and meds q.2 hours (oxy and dilaudid) in addition to her other meds. TPN with 3 rate changes during the night. PICC line with 2 good lumens. I think she had abx - don't remember. BG checks q.4 hours. NA did one of the checks.
patient 3: New admit from ER for CHF exacerbation, only had her for 8 hours of the shift. non-english speaking but had daughter to translate. She was my easiest once I spent about an hour doing the admit, setup, V/S (only twice as she was there only 8 hours), but then her BP started dumping (high 80s/40s) and I had to spend a good 30-60 minutes focused on that.
patient 4: POD2 with wound VAC to RLE, 3 new surgical sites, q.2 hour pulse checks, abx, pain well controlled, little forgetful and confused but stable. this was my 2nd day with him and I had asked day shift the day before for lasix because his LEs were so tight, peeling and discolored I was worried for compartment syndrome (not seriously but dayum they looked awful). he was on heparin and bridging to coumadin so I was chasing his labs and titrating his heparin also. by end of shift we were down to +3 pitting edema (huge improvement from rock hard skin) on surgery leg and +2 in nonsurgical. during the q.2 hour pulse checks (I missed one of them during the night) I had to reposition him and get the surgical leg elevated.
patient 5: bariatric POD1 with N/V unable to hold down water, pain, EtOH and drug abuse HX (I found from day shift during report), but really a very stable patient. I was in there more than q.4 hours as I was staggering her meds so she could try to keep some of them down.
So, hour one (20-21) I did HTT on 3 patients and got meds up to 2100 passed as I suspected I was going to get another patient and I wanted to be ready if/when that happened. Found out about 15 minutes before tranfer I was getting the ED xfer so I was glad I had planned for another patient.
Hour 21-22 passing meds, addressing pain on pax 1 and 2, charting exceptions to HTT, adjusting TPN and replacing all tubing (expired). chlorhexidine baths on the PICC lines. Chart 2 HTTs fully. Check everyone's labs and make sure nothing was crazy. Give insulin like candy.
hour 22-23 pretty much dedicated to new admit.
hour 23 I got 5th patient. HTT on them and keep running all the meds
hours 24-8 I'm bouncing from patient to patient. We had 2 rapids on the unit and everyone was pretty busy. Shift ended at 0730 but day shift as a whole said it seemed like many from night shift were trashed at report. I didn't start charting until 0830 as I was still responding to the uncontrolled pain patients and making TPN changes and trying to give report (we do bedside). There were 6 of us charting from 8-9 and 2 of us from 8-10.
So, new grad, I know I'm lousy with time management but I do try to cluster stuff and anticipate *** coming up (I will dump heparin and maintenance fluids in the rooms (after say 0100 or so) so if the alarm goes off and an RN sees it they might hang the new fluid. I keep my tubing labeled and know when it needs to be changed (all TPN, lipids and abx tubing was changed so I make sure I have that *** before I leave the med room). We ran out of 10mL flushes about 5 am so I was chasing my *** on that for the PICC line patients.
So, pointers on how I could have structured the night better?
That sounds horrific, borderline unsafe from the outside looking in. Any possibility to find a new job? Also you’re basically ICU at this point, you should transfer over if you can and get a raise.
Specializes in Community Health, Med/Surg, ICU Stepdown.
Reading this gave me flashbacks, ahhh! I can't find anything wrong with the way you managed your time. It sounds like you're thorough with your assessments and make good recommendations to the team for your patients. Hospital nursing is hard, and 5 true step-down patients is TOO MANY. No matter how well you manage your time and how fast you run, it's easy for things to fall through the cracks and to feel overwhelmed.
I hope a miracle happens and your unit gets better ratios. If not, time management improves with experience, and you're close to a year of acute care so you will qualify for non bedside jobs soon if you're interested. But feeling overwhelmed by that assignment is not about you or your time management. It's an unsafe assignment.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
I agree that was the Assignment From Hell. I'm shocked and disgusted at how far hospitals are willing to push the staffing envelope, then gaslight nurses about time management.
The charge nurse needs to be keeping close track of the techs to make sure they're not just hiding somewhere.
I know you probably don't have a union. Your assignment would be prime fodder for an unsafe staffing report.
I don't have any useful advice. But be assured that the assignment you described is not appropriate for any nurse, no matter how seasoned.
RN-90
6 Posts
Hats off to you for surviving this night! Five is too many patients for step-down especially when they all sound quite ill. It sounds like you have done many things within your power to help the situation. If these are the unit expectations to manage 5 patients, I might look elsewhere if things don't change.