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pantsheadWelp, I obviously haven't updated this in a good while! The summer has pretty much gone here; we've taken everything out of the gardens and are just waiting for the leaves to fall so we can cover the garden beds.
Really
I started work on July 18th at the teaching hospital in town; it's a Level 1 trauma center (which means, among other things, that the doctors who attend to trauma cases have to be *in* the building, not paged in from home). I'm working on the burn unit, which is an intensive care unit with only 6 beds. It's connected (by management) to a larger surgical intensive care unit down the hall. I start working nights next weekend (I was hired to work nights, but orientation thus far has been during the day).
During orientation, new nurses have a preceptor to work with. The preceptor is a more-experienced nurse who watches everything the orientee does. They don't have a separate assignment of patients, they have the same patients I do. This continues for the first 20 weeks of employment (for the ICUs at this hospital, at least), which is pretty amazingly costly if you think about it! For an average of 60 hours out of every 80, they're paying 2 people to do the work of one person. Our pay periods are 80 hours over 2 weeks, but we usually have classes or workshops on a couple of those days. I would say that about 1/2 of what I need to learn is *how* to do things (there are a lot of procedures we never learned in school, and all of them have to be done according to this hospital's policies), and 1/2 is *what* to do and who to contact (teaching hospitals have residents--doctors who work under the attending physician. The residents change assignments monthly. Except for true emergencies, you always page the resident first when there is a change in a patient. Most ICU patients are managed by at least 2 teams of residents, each with their own attending physician. So, knowing who to call is a big deal!)
Unfortunately, my preceptor wound up getting really sick and was out for 5 weeks. So, I've been passed around to a lot of different preceptors. This is a challenge because your preceptor is really supposed to know how you're doing and help identify (and then work on) areas for improvement. Without much continuity, that's hard to do. I should be with the same preceptor for the last month, though, as long as she stays healthy!
So, what am I actually doing? I'm usually taking care of 1-2 patients, which is pretty normal for an ICU. We have 3 classes of patients: ICU patients, who require frequent monitoring (like, at least once an hour, maybe every 15 minutes); Step-Down patients, who require less frequent monitoring, and Floor patients, who could be on a regular hospital floor but haven't been transferred yet. (Hospital lingo: "The Floor" refers to regular hospital units where mostly-stable patients are recovering from all kinds of things--could be surgery, could be infection, etc... Nurses on the Floor usually are assigned 5 or 6 patients each. They have an aide to help them--usually--but the nurse is expected to give meds to all patients--often 3+ times per shift, per pt!, coordinate transporting them to various tests and scans, help them get washed up, reinforce physical therapy/occupational therapy teaching, and attend to their other needs...family issues, toileting, monitoring them for any changes. "The Unit" refers to intensive care units.)
Hospital policy says an ICU nurse can take care of 3 SD/Floor patients, but only 2 ICU pts at a time. The irony is that *some* ICU patients are actually less work than SD/Floor pts. They are intubated and sedated, with urinary catheters and feeding tubes. As long as their vital signs remain stable (which isn't a given!), they just need to be turned every 2 hours, bathed, have their mouths cleaned every 4 hours, get their meds on time, and monitored for changes. (I say that like it's easy--it can actually be pretty time consuming. But, they're not awake and asking for things!) Burned ICU patients are a different story--they require wound care every day or every other day, which can take hours. SD/Floor patients need all of those things as well (including wound care), and they are usually awake and asking for things, or refusing to do things ("I don't want to do PT until after lunch!") It's not that I mind taking care of them--it's amazing how happy a glass of juice will make someone who hasn't been allowed to eat or drink for days--but it's just more time consuming. A sedated, ventilated patient will never ask for 2 separate glasses, one with just ice in it, and one with half cranberry and half apple juice! Our unit only has one aide (and she doesn't work 24 hours a day), so nurses handle almost everything the patient needs. We also answer the phones on our unit (no secretary)--and sometimes have to explain to families that the more time we spend on the phone answering *every* family members' questions, the less time we spend taking care of their loved one (we strongly encourage them to have one point-person for phone calls).
In my 15 weeks, I've seen a good variety of patients, but I know I've probably barely scratched the surface. We've had several serious burns (like, more than 30% of the body, or significant 3rd degree burns). Burn patients get stabilized first, and then get their burns treated. When someone is burned, they also might have inhalation injuries which can be much more serious than the burns themselves. Just like any other trauma, our priorities are Airway-Breathing-Circulation....without these, it doesn't do any good to start thinking about skin grafts! So, serious burns are almost always ventilated (a tube down the trachea attached to a breathing machine) and sedated (because breathing through a tube would make anyone crazy). They get constant pain medications, and may get paralytic medications too. They have feeding tubes put in to keep their gut working and give them nutrition--it takes thousands of calories a day to heal burn wounds. They (ideally) have central IV lines inserted, which go basically right to the heart and can handle higher volumes of liquid than peripheral IVs in the hand or arm. They may have 6-8 medicines, fluids, and blood products infusing at any given moment. They get looots of fluids, because open burns weep fluid constantly. The ideal is to keep giving fluids until their urine output reaches about 60mL/hour, then start to back off of the fluids. Because of all the fluids, their entire body becomes edematous. We check their blood electrolytes daily and replace them as needed; they get blood products because their blood gets diluted.
Once a burn patient is a little more stable, they probably have their first surgery, in which the burned tissue is removed and pigskin tissue is applied. The pigskin stays in place for several days and the pt's skin can start healing underneath it. For deep burns, though, there's no dermal layer left to heal, and grafts of the pt's own skin or cadaver skin are needed. The pigskin eventually falls off and the burns are assessed; grafts seem to be the next step. When the grafts are taken from the patient, it basically doubles the amount of wounded, painful tissue they have--if the whole back of the leg is burned, and they take grafts from the front of both thighs, they now have 3 major wound sites instead of 1! The graft donation sites aren't very deep, which means they do heal but are painful. Burn patients often have several surgeries. They stay on our unit throughout this time, and then move to a rehab unit when their burns are definitely healing and their wound-care needs aren't quite so intense. This means some patients are with us for months.
We do also get other ICU patients--'routine' surgery patients who had heart arrythmias in the recovery room, 'medicine' patients such as pts with pneumonia who need to be vented and get lots of IV antibiotics, etc... But these patients will stay for a week or 2 (or less) before being sent to other floors.
So....that's a (not very brief) summary of what I've been up to!
Really
I started work on July 18th at the teaching hospital in town; it's a Level 1 trauma center (which means, among other things, that the doctors who attend to trauma cases have to be *in* the building, not paged in from home). I'm working on the burn unit, which is an intensive care unit with only 6 beds. It's connected (by management) to a larger surgical intensive care unit down the hall. I start working nights next weekend (I was hired to work nights, but orientation thus far has been during the day).
During orientation, new nurses have a preceptor to work with. The preceptor is a more-experienced nurse who watches everything the orientee does. They don't have a separate assignment of patients, they have the same patients I do. This continues for the first 20 weeks of employment (for the ICUs at this hospital, at least), which is pretty amazingly costly if you think about it! For an average of 60 hours out of every 80, they're paying 2 people to do the work of one person. Our pay periods are 80 hours over 2 weeks, but we usually have classes or workshops on a couple of those days. I would say that about 1/2 of what I need to learn is *how* to do things (there are a lot of procedures we never learned in school, and all of them have to be done according to this hospital's policies), and 1/2 is *what* to do and who to contact (teaching hospitals have residents--doctors who work under the attending physician. The residents change assignments monthly. Except for true emergencies, you always page the resident first when there is a change in a patient. Most ICU patients are managed by at least 2 teams of residents, each with their own attending physician. So, knowing who to call is a big deal!)
Unfortunately, my preceptor wound up getting really sick and was out for 5 weeks. So, I've been passed around to a lot of different preceptors. This is a challenge because your preceptor is really supposed to know how you're doing and help identify (and then work on) areas for improvement. Without much continuity, that's hard to do. I should be with the same preceptor for the last month, though, as long as she stays healthy!
So, what am I actually doing? I'm usually taking care of 1-2 patients, which is pretty normal for an ICU. We have 3 classes of patients: ICU patients, who require frequent monitoring (like, at least once an hour, maybe every 15 minutes); Step-Down patients, who require less frequent monitoring, and Floor patients, who could be on a regular hospital floor but haven't been transferred yet. (Hospital lingo: "The Floor" refers to regular hospital units where mostly-stable patients are recovering from all kinds of things--could be surgery, could be infection, etc... Nurses on the Floor usually are assigned 5 or 6 patients each. They have an aide to help them--usually--but the nurse is expected to give meds to all patients--often 3+ times per shift, per pt!, coordinate transporting them to various tests and scans, help them get washed up, reinforce physical therapy/occupational therapy teaching, and attend to their other needs...family issues, toileting, monitoring them for any changes. "The Unit" refers to intensive care units.)
Hospital policy says an ICU nurse can take care of 3 SD/Floor patients, but only 2 ICU pts at a time. The irony is that *some* ICU patients are actually less work than SD/Floor pts. They are intubated and sedated, with urinary catheters and feeding tubes. As long as their vital signs remain stable (which isn't a given!), they just need to be turned every 2 hours, bathed, have their mouths cleaned every 4 hours, get their meds on time, and monitored for changes. (I say that like it's easy--it can actually be pretty time consuming. But, they're not awake and asking for things!) Burned ICU patients are a different story--they require wound care every day or every other day, which can take hours. SD/Floor patients need all of those things as well (including wound care), and they are usually awake and asking for things, or refusing to do things ("I don't want to do PT until after lunch!") It's not that I mind taking care of them--it's amazing how happy a glass of juice will make someone who hasn't been allowed to eat or drink for days--but it's just more time consuming. A sedated, ventilated patient will never ask for 2 separate glasses, one with just ice in it, and one with half cranberry and half apple juice! Our unit only has one aide (and she doesn't work 24 hours a day), so nurses handle almost everything the patient needs. We also answer the phones on our unit (no secretary)--and sometimes have to explain to families that the more time we spend on the phone answering *every* family members' questions, the less time we spend taking care of their loved one (we strongly encourage them to have one point-person for phone calls).
In my 15 weeks, I've seen a good variety of patients, but I know I've probably barely scratched the surface. We've had several serious burns (like, more than 30% of the body, or significant 3rd degree burns). Burn patients get stabilized first, and then get their burns treated. When someone is burned, they also might have inhalation injuries which can be much more serious than the burns themselves. Just like any other trauma, our priorities are Airway-Breathing-Circulation....without these, it doesn't do any good to start thinking about skin grafts! So, serious burns are almost always ventilated (a tube down the trachea attached to a breathing machine) and sedated (because breathing through a tube would make anyone crazy). They get constant pain medications, and may get paralytic medications too. They have feeding tubes put in to keep their gut working and give them nutrition--it takes thousands of calories a day to heal burn wounds. They (ideally) have central IV lines inserted, which go basically right to the heart and can handle higher volumes of liquid than peripheral IVs in the hand or arm. They may have 6-8 medicines, fluids, and blood products infusing at any given moment. They get looots of fluids, because open burns weep fluid constantly. The ideal is to keep giving fluids until their urine output reaches about 60mL/hour, then start to back off of the fluids. Because of all the fluids, their entire body becomes edematous. We check their blood electrolytes daily and replace them as needed; they get blood products because their blood gets diluted.
Once a burn patient is a little more stable, they probably have their first surgery, in which the burned tissue is removed and pigskin tissue is applied. The pigskin stays in place for several days and the pt's skin can start healing underneath it. For deep burns, though, there's no dermal layer left to heal, and grafts of the pt's own skin or cadaver skin are needed. The pigskin eventually falls off and the burns are assessed; grafts seem to be the next step. When the grafts are taken from the patient, it basically doubles the amount of wounded, painful tissue they have--if the whole back of the leg is burned, and they take grafts from the front of both thighs, they now have 3 major wound sites instead of 1! The graft donation sites aren't very deep, which means they do heal but are painful. Burn patients often have several surgeries. They stay on our unit throughout this time, and then move to a rehab unit when their burns are definitely healing and their wound-care needs aren't quite so intense. This means some patients are with us for months.
We do also get other ICU patients--'routine' surgery patients who had heart arrythmias in the recovery room, 'medicine' patients such as pts with pneumonia who need to be vented and get lots of IV antibiotics, etc... But these patients will stay for a week or 2 (or less) before being sent to other floors.
So....that's a (not very brief) summary of what I've been up to!
