Tuesday, August 22, 2006

Guilt Trips

I think that's enough messing around with the template for one day! Still lots to do, but we're getting there.

I had one of those shifts yesterday which involved lots of TASKS. Gotta love those nursing tasks. Let's see if I can remember them all:
  • 12 sets of hourly vitals, including complicated fluid balance.

  • Primary assessment (A,B,C,D,E)

  • Secondary assessment (body systems)

  • Four antibiotic doses

  • Six sedation/analgesia boluses, and one muscle relaxant

  • Eight or nine doses of various oral medications

  • Three blood gases, gentamicin level, thyroid function and cortisol levels

  • Four ETT suctions

  • One sponge bath and linen change

  • Concentrate frusemide and milrinone infusions to reduce volume

  • Switch three other infusions to 10% dextrose to offset lack of nutrition somewhat

  • Switch feeds to more concentrated formula for same reason

  • Re-tape ETT (tapes get a bit wet with secretions and loose, which is a safety issue)

  • Position for mobile chest xray

  • Change arterial line transducer set and infusion.

  • Cardiac rounds

  • Unit rounds

  • Multidisciplinary rounds

  • Assist colleague to complete checks on a ventilator she was unfamiliar with

  • Assist colleague with extubating her patient

  • Assist various colleagues with various drug checks

  • Troubleshoot, then remove a peripheral cannula that was leaking

  • Wean ventilation ever so slowly, due to patient's overall fragility and history of not tolerating sudden changes in treatment

  • Handover, one at each end of shift.
When I write it down, it seems like a lot which makes me feel better because in actual fact I didn't finish everything I wanted to, and was rushed at shift change. At the end of the day I hadn't finished vitals for the previous two hours, and this was with several nurses pitching in to help. It always makes me feel deflated because if I'd only crammed more into the day, organised differently, etc.

If only.

The above list doesn't even begin to cover it, because it's TASKS. This is something healthcare management often does not comprehend when considering nursing staff ratios, although I will say for the record that I am extremely fortunate to work in a facility that very sensibly staffs ICU patients at one to one, or at most one to two.

What is the list missing? Constant assessment and monitoring. Do I do an assessment at the start of the day, then stop? Of course not. Critical care nursing is about watching for change, watching for trouble, looking for the previously-unnoticed problem. Planning (I almost want to say, scheming.) Talking with the family, since you're sharing space with them for 12 hours. Speaking with the team behind you. In yesterday's case, negotiating between them since everybody seemed to have a different idea of The Right Thing To Do. Supporting. Seeking confirmation. Seeking reassurance. Answering question after question after...

These things are difficult to quantify, and difficult to time. Often impossible to plan for. I know I have time management issues, always have done, even after seven years as an RN and five in intensive care. Can't do much more than try to improve, every day.

Nurses guilt trip themselves a great deal, it seems to me. The good ones get over it. I felt bad about the way the shift ended yesterday, but it's breakfast time now and I'm over it.

Mmmmmmm. Bagels.
Posted by PaedsRN at 1:20 PM

Anonymous S. R., at 8:19 PM  

What about signing the care plan 10X? Or education paper work?

Blogger PaedsRN, at 4:03 AM  

I don't really understand what signing the care plan 10X means... but certainly there's paperwork involved in precepting, if that's what you mean :)

Anonymous S. R., at 10:56 AM  

For every patient, we have a care plan that can be 2-7 pages long with numerous interventions and desired outcomes. The RN has to initial each that he or she plans to implement as well as sign the top of each page. Over and over.

Blogger Intelinurse2B, at 11:27 AM  

How long does it take before you are able to start "getting over" things like that? New grads and students don't seem to posses this skill...

Anonymous bamanurse, at 5:10 PM  

Did you list tranfer sheets?

Blogger PaedsRN, at 6:26 PM  

I'm still not entirely over it, inteli! This morning I've been thinking about how I can be more rigorous with the basics, like some of my colleagues are. Which I guess makes me really anal, since it's my day off. Sad but true.

However, to answer your question: I think by year three or four post-grad, most nurses should be getting to the point where they understand how to release the events of the previous day and get on with the next one. Those that don't, as has often been remarked, quickly burn out.

bama, I don't really know what a transfer sheet is either, but am happy to bundle all such time-consuming activities and label them PAPERWORK... the bane of all our lives!

Blogger kevin3951, at 6:54 AM  

The above list doesn't even begin to cover it, because it's TASKS. This is something healthcare management often does not comprehend when considering nursing staff ratios...

You hit the nail on the head right there.

Blogger I am a Milliner's Dream, a woman of many "hats"..., at 2:48 PM  



Blogger genderist, at 5:54 PM  

Our RTs always changed the ETT tape, but we had to be there to assist them... so it still counted as a time suck.

Blogger genderist, at 10:40 PM  

You should have totally ended that with:

"and a partridge in a pear tree"

Blogger PaedsRN, at 1:20 AM  

The thing is, by the end of the shift I would've EATEN the partridge with a little sage stuffing and a nice pinot gris ;)

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