Wow...the past few weeks have been CRAZY busy. First and foremost, I took my boards on 6/17 and passed...yippee!!!!! 75 questions, 22 select all, 2 put in order, and one diagram. TONS of infection control and prioritization. It was overall not as bad as I had anticipated, but stressful none the less. A few of my classmates have taken theirs in the past 2 weeks as well, and I am happy to report that we have a 100% passing rate so far :-). Good luck to those of you sitting for it in the coming weeks.
Now on to the good stuff!!
The learning curve in the CSU is insane. I never thought that I would learn so much in such a short period of time. Drugs, procedures, drugs, assessments, drugs, charting, drugs, labs, and did I mention drugs :-). I never realized how drug intensive our unit is, nor did I ever realize that drugs and their effects on the body was going to be so complicated. alpha, beta-1, beta-2, inotropic, chronotropic, direct or indirect sympathomimetic...it goes on and on. So many decisions go into the choice of drugs, and the time frame for choosing seems like microseconds...do they need volume...whats the SVR...why is my index low...are they bleeding...yikes!!!!! Glad I am not the one making those decisions (yet).
I have spent my on unit time taking simple vascular cases, stable hearts and thoracotomies (well...with one balloon pumped 2 day post CABG with an EF of 15%, and one 4 hour postop CABGx4, with an aortic and mitral valve replacement and a tricuspid ring thrown in, but I was not the primary on either of those). So, Carotids, Fem-pop's, and thoracotomies have been my jumping off point, and according to my preceptors, I am doing better than many of the ICU/floor nurses that have come into the unit. I am getting comfortable with my assessments, although I find myself constantly questioning what it is that I am hearing. The more I listen to, the more comfortable I get, so in the few quiet moments we have, I try to listen to other patients in the unit so I can get more experience. The charting has come quite easily since we are computerized, and I am the type that tends to err on the side of too much information, so I fit right in with the type A CSU personalities. I really LOVE all of the monitors and lines that we have on our patients because it gives immediate feedback on the drugs you are giving. I guess I tend to be the instant gratification type, so it really makes me giddy when I up my levo, and within a very short period of time, I see my SVR and BP coming up...I'm a nerd I know :-).
I took 2 patients for the first time last night (2 is our max unless there is some crazy emergency), and I have to tell you...I was comfortable with the flow of one patient, and all of my "stuff" was getting done. 2 patients is quite a bit more than 1...especially when you throw in 3 floor codes (we are code team/CAT team, so we go to all codes/CAT calls), 2 CAT calls, and 2 emergency transfers to our unit. I had a fairly stable patient that was going for a pacer this morning (aortic valve replacement knocked out the conduction to his ventricles, so he was being epicardially paced, but was otherwise stable), and an intubated CABGx3 that had his chest opened on the unit a week ago because of a pacer wire pull nicking the RCA and causing profuse bleeding. So, between suctioning, oral care, turning, keeping the sedation running, hanging antibiotics, titrating drips to keep my BP's in range, and helping out with transfers, codes, and CAT calls, my night was CRAZY. To top it off, we started out with 2 nurses, me, and 4 patients in the unit. By the end of the night, we had 6 patients, so it was a good thing I was there.
Now for a little bit on loyalty and commitment to your place of employment. Last night could have been a lot less crazy than it was, but one of our nurses called in. It is a blessing and a curse working where I do...a blessing because we have tons of autonomy, a great team of doctors and nurses, a state of the art facility, and lots of toys :-). It is a curse because it is not easy to staff, and if we have a call in, we can't just "float" a nurse over. There are not a lot of nurses that have the skill set to take care of the population of patients we get, and of the ones that do, many are not trained on our equipment and computer system. Because of this, call ins are a REAL problem for us. My personal feeling on it is that when you sign up on the schedule, you should be there unless you are REALLY sick...I have gone to work feeling a bit off before, and I am sure I will do it many more times. We are VERY luck to have jobs, and even luckier to have jobs at the place and with the team we have. We don't work at Walmart, and can't be replaced by any Tom, Dick, or Harry, so erroneous call outs are not cool (especially when it ends up leaving the new grad with 2 patients to care for while her preceptor is keeping 2 codes alive)!!!! If you want the autonomy, the high acuity patients, and the unit differential...show some loyalty to your unit. If you want the flexibility to call out and not have people put in a bad place because of it, go back and work on the floor where there are 5 people waiting in line to come in and get some extra hours. OK, off soap box now....suffice it to say, when your staff consists of less than 25 people for a 9 bed unit with 1:1 or 1:2 ratios, every person is needed. DON'T call out unless you are dying...your co-workers will really not like you (especially when it is a regular occurrence).
I am working on a "what I have learned in the CVICU" post with drug info, procedure info and other fun stuff, but I wanted to give a short update on how things are going. I am going to try to make more frequent, short posts in the future so things don't get so overwhelming and all over the place :-).
Monday, July 6, 2009
Tuesday, June 16, 2009
Death
Death is something that has or will touch all of our lives at one time or another. As nurses our lives are touched by death more often than most. It is a hard experience no matter how many times you go through it, and as a brand spankin new grad it is especially hard (I think). I saw my share of death as a tech/extern on my unit, but it never hit me the way it did last week. We have had a run of patients that have done very poorly postoperatively, and therefore have ended up staying in our unit for more than the typical 2-3 days. One patient in particular had been on the unit since the week of my hospital orientation. This patient was a poor surgical candidate to begin with, and had multiple issues post op (unstable rhythms, unstable respiratory status with multiple intubations, and acute renal failure). The patient was a candidate for a LVAD (basically a short term artificialy pump to take the workload off of the heart), but the surgeons decided against it. Anyways...suffice it to say that after many years of noncompliance with medications and health issues, this patient was not doing well after surgery. In the 3 weeks that I have been orienting on the floor, I was in and out of this patients room for manny different reasons, but I was never assigned directly to this patient. The patient had sustained runs of Vtach my first night on orientation, so we spent a bunch of time in there trying to get a more stable rhythm (pt was extubated and communicating that first night). The patient was on SLED (a form of continuous dialysis) by my second night of orientation, so we spent time in the room learning about the concepts of SLED and how to run the machine (pt was reintubated by this time, but could still respond to commands). On my 3rd night of orientation, the patient coded and we had to do compressions. I arrived at work on my 4th night of orientation, and took report on my patient. I noticed a bunch of family around the room of the patient I had spent so much time with. I wondered what was going on, but had my own patient to deal with, so I did not wander down to investigate. As the evening wore on, the family came and went, and hospital coordinators, doctors, and nurses were all milling around outside of the room. Finally when my patient was resting, I wandered down to see what was going on. Turns out the family had decided to make the patient a DNR and to terminally extubate the following morning. Apparently a terminal extubation is a big deal and requires lots of doctor consults, and a crazy number of signatures. Now as an aside, the nurse caring for this particular patient was not at the top of the list of caring and compassionate people. He is a very knowledgable and thorough nurse, but not the type that holds the patients hand. After the family made the decision, and went home for the night, the nurse spent probably 90 minutes spit shining the patient. When I went in to help him turn, I asked him what he was doing in there for so long, and he said that he wanted to make sure that the patient spent their last moments clean and comfortable. That really touched me coming form someone that I looked at as a very thorough nurse, but not the touchy feely type. He was talking to the patient and saying how everything was going to be ok soom and that there would be no more pain. he explained how we would be sure to make the patient comfortable. I was touched that he made the extra effort to talk to the patient and make sure they they knew everything was going to be ok. We hadn't been out of the room for more than 10 minutes when the monitors started alarming...the patient had a heart rate of 44 and dropping. We went into the room, the nurse took the patients hand and said it is all going to be ok now...it is ok to go. Within 3 minutes, the patient was gone. This was a first for me in many ways. It was the first patient that I had previously interacted with that I spent the last minutes of their life with (we see a fair amount of death, but usually the ones that don't make it never recover consciousness after surgery and we never really interact with them). It was the first time I saw that even nurses that are not the touchy feely type have compassion...they just show it in different ways. It was the first time I put my stethescope to a patients chest and did not hear heart tones. It was the first time I was the one to say "they are gone". Life is full of firsts, and I will always remember the patients who's last moments gave me so many firsts.
Thursday, June 11, 2009
Decision making
Today I want to talk about decision making. It is not an area in which I thought I was hugely lacking skill, but when the rubber meets the road, it turns out that I royally SUCK at it :-). OK, maybe not royally suck, but I could use some brushing up in that area. I have been on unit orientation for a total of 3 shifts now (we have 2 -12 hour shifts a week and one day of classroom stuff). I have taken one patient each shift, and lucky for me, it was the same patient for the first 2 shifts (Yippee for consistency). Anyways, middle of my third shift comes around, and the notion strikes me that I have not made one decision on my own. Everything that I do I ask my preceptor...should I do this, should I chart this, should I time this lab for 4:00 since we need it by 5:30? About the time I had asked her the 800th question for the night, I had the revelation that I need to start making some decisions on my own. Orientation is a time for learning, but it is also a time for taking control of and responsibility for your actions. I apparently am sooo darn scared of the consequences if I screw something up that I am not even willing to decide if a lab can be timed for 4 or 5 am...what the hell is that???? I have been through more school than most people I know combined, and I consider myself to be a fairly intelligent individual. I don't seem to have a problem making decisions in day to day life, or in training my dogs or horses. I didn't really have a problem with decision making in the clinical setting, so now why am I all of a sudden a decision making retard? This has been the topic of my thoughts for the past 48 hours or so. I have pretty much decided that I don't feel like I have enough knowledge to be able to make the correct decision for my patient population. I am scared of the consequences of a wrong decision, and therefore I have resprted to turning to my preceptor for EVERYTHING (i.e I am going to clear the pumps at 6:10 instead of 6:00...is that OK? I was running a little late and forgot...jeez...what was I thinking). I posed my problem to my preceptor, and she laughed. In my head I was thinking...yeah...ha ha ha really funny. I am glad that I could be your joke for the night, ad then she said the magic words that changed my mind about the whole thing. She said..."You are asking me tons of questions, but you are not asking me to make the decisions. You are asking me if it is ok if you do A instead of B. If you were asking me what should I do, A or B, I would be worried, but since you are coming to me with your decision made, and you are just checking the answer, I am not worried. A few more days of making the correct decisions, and you will have a bit more confidence." A little light went off in my head, and I felt sooo much better. I am not really a decision making retard, I am just cautious, and cautious is good :-). Sooo, for those of you out there that are having issues with decision making, just make sure you decide what course of action you think is best, and then go to your preceptor. That way it is really YOU that has made the decision, and your preceptor is just your double check so no one dies (or gets hurt).
I have made a decision reguarding this blog (baby steps ya know). Instead of painfully rehashing everything that I do on every shift, I will take the main points I came home with, and the main things I learned and make them nice little bullet points, so for this week this is what we had:
- chest tube leaks show up as bubbling in the water seal chamber and sound like ping pong balls in the patient's chest...I know they taught us this in school, but it sticks so much better when you see it in action!!! I had a thoracotomy pt this week that had a crazy air leak ( and a heart that was deviated to the opposite side of the chest due to lung collapse...it was really cool).
- IV amiodarone should be run centrally whenever possible. Small boluses can go peripherally, but if you are gonna hang it for any length of time, get a central line...it is not pretty if it infiltrates (did not get first hand experience, but saw pictures)
- Levophed increases SVR, has a positive inotropic action, and somewhat dilates the coronaries. It is a good drug for hypotension, but make sure your patient has enough volume before you go jacking up the rate. At our institution, the docs only like to go to about 20-30mcg/min with the Levo before they switch to Vasopressin (which apparently does a better job of clamping down the peripheral vasculature)
- Low cortisol levels can cause low BP because of cortisols action in the renin-angiotensin-aldosterone cycle. My patient's SBP was hovering in the 60-70 range on 2 of Levo, so the docs wanted a cortisol level drawn to see if that was the cause of the hypotension. Cortisol levels came back fine, and we upped th Levo to 4 and the SBP went up to about 90. Pt was non symptomatic with SBP of 90, and got up to the chair with ease. My guess is thet their norm was low to begin with (but that is just my not yet very experienced opinion!!)
-Time management is everything!! I need to devise a cheat sheet or something now that I have a better idea of the daily flows. All of the "stuff" that needs to get done in an ICU setting is overwhelming, and I really need a vidual so I can be sure I finish everything i need to get done.
- Everyone makes mistakes, or forgets things...even the seasoned super nurses, so at the end of the day if your patient is still alive not much else matters (for now anyway) :-). They are not going to remember if you forgot to do the 24 hour chart check, or if you forgot to order that lab and had to leave it for the next shift. Treat each patient as you would want your family to be treated, smile, and do everything you can to make them comfortable...the rest will fall into place!!!
I have made a decision reguarding this blog (baby steps ya know). Instead of painfully rehashing everything that I do on every shift, I will take the main points I came home with, and the main things I learned and make them nice little bullet points, so for this week this is what we had:
- chest tube leaks show up as bubbling in the water seal chamber and sound like ping pong balls in the patient's chest...I know they taught us this in school, but it sticks so much better when you see it in action!!! I had a thoracotomy pt this week that had a crazy air leak ( and a heart that was deviated to the opposite side of the chest due to lung collapse...it was really cool).
- IV amiodarone should be run centrally whenever possible. Small boluses can go peripherally, but if you are gonna hang it for any length of time, get a central line...it is not pretty if it infiltrates (did not get first hand experience, but saw pictures)
- Levophed increases SVR, has a positive inotropic action, and somewhat dilates the coronaries. It is a good drug for hypotension, but make sure your patient has enough volume before you go jacking up the rate. At our institution, the docs only like to go to about 20-30mcg/min with the Levo before they switch to Vasopressin (which apparently does a better job of clamping down the peripheral vasculature)
- Low cortisol levels can cause low BP because of cortisols action in the renin-angiotensin-aldosterone cycle. My patient's SBP was hovering in the 60-70 range on 2 of Levo, so the docs wanted a cortisol level drawn to see if that was the cause of the hypotension. Cortisol levels came back fine, and we upped th Levo to 4 and the SBP went up to about 90. Pt was non symptomatic with SBP of 90, and got up to the chair with ease. My guess is thet their norm was low to begin with (but that is just my not yet very experienced opinion!!)
-Time management is everything!! I need to devise a cheat sheet or something now that I have a better idea of the daily flows. All of the "stuff" that needs to get done in an ICU setting is overwhelming, and I really need a vidual so I can be sure I finish everything i need to get done.
- Everyone makes mistakes, or forgets things...even the seasoned super nurses, so at the end of the day if your patient is still alive not much else matters (for now anyway) :-). They are not going to remember if you forgot to do the 24 hour chart check, or if you forgot to order that lab and had to leave it for the next shift. Treat each patient as you would want your family to be treated, smile, and do everything you can to make them comfortable...the rest will fall into place!!!
Sunday, May 31, 2009
My first patient
Last night was my very first night as a GN on my Unit. It was exciting and terrifying at the same time, but it was a HUGE learning experience (which I am sure every shift will be). I figured since we are the highest acuity unit in the hospital, and I am the first GN that we would spend a few nights with me just shadowing and not doing much. I had my little notebook and pen so I could write down all of the information I might need at a later date, and my stethescope (with an engraved puppy dog paw on it thanks to my wonderufl boyfriend)...I was ready to go!!! I sat down with my preceptor to get report, and that is when she told me that she was taking 2 patients and one of them would be mine. I just kind of looked at her while my mind processed the words coming out of her mouth...mine...as in my own patient...as in I am actually responsible for someone tonight...what the heck was she thinking...not on my FIRST day. I think she saw the look of terror in my eyes, took pity on me, and said...don't worry you will be fine and I will be right there with you if you need anything. My mind was going through all of the possibilities and trying to make sense of what I was hearing. I had taken 4 patients for most of my preceptorship, but they were all fairly healthy and stable individuals. Now it is my first day, and I am being asked to take care of one person...why am I so scared. She said she would be right there to help me...what the heck is my problem...why on earth am I having a panic attack. That went on for about 2 more minutes while I tried to get myself calmed down and under control enough so I could take report on my patient. My patient...has a certain ring to it don't ya think :-). Anyways, I finally got myself under control enough to listen to what the day nurse had to say. Pleasant patient, arterial leg thrombus, no pulses below the knee...even with dopplar, arterial infusion catheter with TPA and heparin infusing, also on nitro drip. Goal for the night...keep PTT between 30 and 60, and keep SBP above 140, but below 170 (the doc wanted the BP a bit high to try and help to perfuse the leg as much as possible), pt going to cath lab in morning, so consents and safety checks must be completed. OK....I can do this. I know what drugs he is on and why, I know what has to be done tonight, I have a list of labs a mile long that must be run every 4 hours, but I have 2 peripheral IV's, and one arterial port...I CAN do this!!
We listened to report on the other patient my preceptor was taking, and then went to meet our patients and do the initial assessment. I have NEVER been so scared to talk to a patient as I was last night...my introduction was probably the least confidence inspiring introduction in the history of nursing, but I got it done, and my patient was very pleasant and happy that he was the lucky recipient of 2 nurses for the night (even if one of them was a brand spanking new grad that could barely utter her name ina cohesive sentence). After introductions, my preceptor explained that she was orienting me to the unit and that she would be with me all night following up my assessments with her own. My patient was surprisingly understanding and my preceptor told me to go ahead and start my assessment. I amazingly completed my assessment without losing my ability to speak again, and thankfully other than the cool and pulseless lower leg and oozing infusion port site, my patient had an unremarkable assessment. My preceptor did her assessment while I checked the tubing, connections, and concentrations on all of the IV's. We tucked the patient in with a warm blanket around the cool leg and said we would be back in a few minutes to check in and change the dressing on the infusion port. After we left the room, my preceptor asked me what abnormalities I found in my assessment, and thankfully she agreed completely, so it was then off to assess her patient. Scenario repeated except this time my preceptor was in charge, and I just did a backup assessment so that I would be able to hear the patients rough, crackly breath sounds and artificial heart valve :-).
After the 2 assessments, we talked a bit about how my preceptor organizes her time, and she asked me how I wanted to organize the tasks for the shift. I thought about it and said we should chart our first assessment, get the labs and meds done and then get the dressings changed, and then do the rest of our charting. A word about charting...on our unit, vitals have to be verified at least every hour, more often depending on what kinds of meds the patient is on, or what procedure they had done. We also have to do assessments every 2 hours, so the charting can be monumental. I have not taken the computer charting class for nurses yet (that is tomorrow), so my preceptor did the charting. We did discuss all of our findings, as well as why she does certain things, so I think it actually worked out better that way because I was able to pay attention to what she was doing and why rather than worry about if I was doing something right. In the middle of our charting efforts, we got a call from the lab saying that my patient's PTT was more than 115. I was horrified...why...on my first night...why couldn't my patient cooperate...why does the PTT have to be so high all of a sudden...why after you have been in therapeutic range all day did you have to jump up now? My preceptor was great...she is the best...REALLY...she immediately snapped me out of my downward spiral and said...what should we do? My immediate thought was...high PTT...oozing infusion port site...uh-oh...we need to turn down the heparin. Well, as many of you may know...that is not exactly the right answer :-) (not exactly wrong either though, so I don't feel too bad). Thankfully I fully thought through things before I opened my mouth, and I think she took pity on me because of the silence. She said...why do you think the PTT is that high...well DUH...I know that one...because of the heparin. Right she said, and what do we know about these labs...Oh yeah...I forgot...the day nurse said she drew them from the infusion port that just happens to be infusing the heparin. Right again...so...what should we do? Pull another PTT I asked....DING DING DING...CORRECT!!! Woohoo I am thinking...now if she will just walk me through my entire career like that everything will be hunky dory. So, we proceed to draw more labs from one of the other IV's, and send it down for a STAT ptt...comes back a little bit later, and guess what...PTT is less than 30. YIKES I think...why me...now it is too low and there will be more thrombi to deal with...yikes...what now. Well, that is exactly what my preceptor said...what now? Well, in my head I say...we have a double checked PTT, a patient that needs to be within a certain range, and we are not within that range...do I need more info? No...I can implement now...what implementation do I perform? Up the heparin a bit of course :-)...DING DING DING...correct again!!! I felt pretty good, even though we had to talk about it a bit before I figured out what to do. I think with time, it will come a bit easier, and for now, my patient was back in therapeutic range (we sent 2 more PTT's in the next 4 hours to be sure).
The PTT debacle was in a way the highlight of my night. Of course I got to perform lots of skills (central line dressings, suctioning vent patients, hanging tube feeds, antibiotics, and various other drips, eye care for a patient with ulcerated sclera, and more lab draws than I though possible), I learned about our charting system, and our monitors, and tons of other things, but in the end, the critical thinking is what this whole job is all about. There is a saying in my unit that "we get paid for what we know, not what we do", and I learned within the first 3 hours of my very first night on the unit that this saying holds very true. I have spent most of nursing school going through the motions of learning how to critically think, and now I need to learn how to put that in to practice in my day to day career. Thankfully I am now part of an AWESOME team of nurses that will spend the next 9-12 months training me and mentoring me and helping shape me into a great CSU nurse.
We listened to report on the other patient my preceptor was taking, and then went to meet our patients and do the initial assessment. I have NEVER been so scared to talk to a patient as I was last night...my introduction was probably the least confidence inspiring introduction in the history of nursing, but I got it done, and my patient was very pleasant and happy that he was the lucky recipient of 2 nurses for the night (even if one of them was a brand spanking new grad that could barely utter her name ina cohesive sentence). After introductions, my preceptor explained that she was orienting me to the unit and that she would be with me all night following up my assessments with her own. My patient was surprisingly understanding and my preceptor told me to go ahead and start my assessment. I amazingly completed my assessment without losing my ability to speak again, and thankfully other than the cool and pulseless lower leg and oozing infusion port site, my patient had an unremarkable assessment. My preceptor did her assessment while I checked the tubing, connections, and concentrations on all of the IV's. We tucked the patient in with a warm blanket around the cool leg and said we would be back in a few minutes to check in and change the dressing on the infusion port. After we left the room, my preceptor asked me what abnormalities I found in my assessment, and thankfully she agreed completely, so it was then off to assess her patient. Scenario repeated except this time my preceptor was in charge, and I just did a backup assessment so that I would be able to hear the patients rough, crackly breath sounds and artificial heart valve :-).
After the 2 assessments, we talked a bit about how my preceptor organizes her time, and she asked me how I wanted to organize the tasks for the shift. I thought about it and said we should chart our first assessment, get the labs and meds done and then get the dressings changed, and then do the rest of our charting. A word about charting...on our unit, vitals have to be verified at least every hour, more often depending on what kinds of meds the patient is on, or what procedure they had done. We also have to do assessments every 2 hours, so the charting can be monumental. I have not taken the computer charting class for nurses yet (that is tomorrow), so my preceptor did the charting. We did discuss all of our findings, as well as why she does certain things, so I think it actually worked out better that way because I was able to pay attention to what she was doing and why rather than worry about if I was doing something right. In the middle of our charting efforts, we got a call from the lab saying that my patient's PTT was more than 115. I was horrified...why...on my first night...why couldn't my patient cooperate...why does the PTT have to be so high all of a sudden...why after you have been in therapeutic range all day did you have to jump up now? My preceptor was great...she is the best...REALLY...she immediately snapped me out of my downward spiral and said...what should we do? My immediate thought was...high PTT...oozing infusion port site...uh-oh...we need to turn down the heparin. Well, as many of you may know...that is not exactly the right answer :-) (not exactly wrong either though, so I don't feel too bad). Thankfully I fully thought through things before I opened my mouth, and I think she took pity on me because of the silence. She said...why do you think the PTT is that high...well DUH...I know that one...because of the heparin. Right she said, and what do we know about these labs...Oh yeah...I forgot...the day nurse said she drew them from the infusion port that just happens to be infusing the heparin. Right again...so...what should we do? Pull another PTT I asked....DING DING DING...CORRECT!!! Woohoo I am thinking...now if she will just walk me through my entire career like that everything will be hunky dory. So, we proceed to draw more labs from one of the other IV's, and send it down for a STAT ptt...comes back a little bit later, and guess what...PTT is less than 30. YIKES I think...why me...now it is too low and there will be more thrombi to deal with...yikes...what now. Well, that is exactly what my preceptor said...what now? Well, in my head I say...we have a double checked PTT, a patient that needs to be within a certain range, and we are not within that range...do I need more info? No...I can implement now...what implementation do I perform? Up the heparin a bit of course :-)...DING DING DING...correct again!!! I felt pretty good, even though we had to talk about it a bit before I figured out what to do. I think with time, it will come a bit easier, and for now, my patient was back in therapeutic range (we sent 2 more PTT's in the next 4 hours to be sure).
The PTT debacle was in a way the highlight of my night. Of course I got to perform lots of skills (central line dressings, suctioning vent patients, hanging tube feeds, antibiotics, and various other drips, eye care for a patient with ulcerated sclera, and more lab draws than I though possible), I learned about our charting system, and our monitors, and tons of other things, but in the end, the critical thinking is what this whole job is all about. There is a saying in my unit that "we get paid for what we know, not what we do", and I learned within the first 3 hours of my very first night on the unit that this saying holds very true. I have spent most of nursing school going through the motions of learning how to critically think, and now I need to learn how to put that in to practice in my day to day career. Thankfully I am now part of an AWESOME team of nurses that will spend the next 9-12 months training me and mentoring me and helping shape me into a great CSU nurse.
Hospital Orientation
It has been an exciting week in my world!!!! Well some of it was :-). After spending an AWESOME Memorial Day weekend at an agility trial with my dog (she did REALLY well, but I won't digress), I hit the ground running on Tuesday with hospital orientation. Tuesday and Wednesday were each 8 hours of agony as I was required to sit through general orientation AND clinical orientation for the second time at the same hospital. I tried very hard to look on the bright side, and make the best of it because it was after all the beginning of my new career!! I did learn a few things: playing a 3/5 or a 5/9 is NEVER a good idea in Texas Hold-em, the White jewel in Bejeweled 2 is worth the most points, and I really like Pac-Man. I also got to practice tying up my fellow orientee's, and I think we probably have the BEST hospital education director on the planet...she ROCKS!!! Various and sundry other tasks were performed over the course of those 2 days, but I will not bore you with the details for fear that I might lose your attention to a game of Texas Hold-em or Pac-Man.
Thursday was Nursing Orientation, and while it was about as exciting as a good swift kick to the head, we did learn LOTS of very useful information. I guess it is better to get all of the housekeeping stuff out of the way first so that when we do start on our units there will be more time for the meat and potatos so to speak. Pharmacy, Laboratory, Pain management, Wound Care, Surgery Services, Respiratory, and the Critical Care Nurse Specialist all came in and talked to us about their roles in the hospital, and our responsibilities to their specific departments. It was a good general overview of the day to day operations, and how they affect the nursing staff. We also got to have a short Graduate Nurse Orientation where they gave us our rounding schedules and talked to us about what was expected of us over the next 10 weeks.
A little bit about our GN program. It is a 10 week program with classroom, unit clinical, and off unit clinical experiences. We have 18 new grads, and 3 people to act as our GN team leaders (One for our Med-Surge nurses, one for the specialties (Ortho, Peds, Oncology, etc.), and one for the critical care areas and the heart hospital). We are signed up to attend basic EKG, 12 lead EKG interpretation, ACLS/PALS, and various other classes depending on our specialty. We have off unit clinical time with PT/OT, Wound and Ostomy Care, Repiratory Therapy, the Diabetes Educator, and some of us spend a day in the OR, a day in the PACU, and a day with the RT learning about Vents. Each week we also have a 4 hour GN enrchment seminar in which different speakers come in and talk to us about stuff like Documentation, Time Management, Medications and Mecication errors, and other things of importance to new grads. All of that, and we still have to do 2-3 shifts a week on our unit with our preceptor, so it will be a busy 10 weeks. At the end of the 10 week new grad internship, we have a skills validation fair and a new grad congratulations luncheon, and then we are sent back to our units to either finish up our unit orientation, or to start with our own patient assignments. Those of us in critical care areas then immediately start with the critical care class and rotation which is very similar to the new grad internship, except with critical care concepts. I will talk about that more once it gets a bit closer.
Most of the GN's have to do 7a-3p Monday through Friday for the first few weeks, but because my orientation will run a bit differently, I am doing 7p-7a 12 hour shits 2 nights a week, and then coming in during the day for the off unit stuff. This is going to make the next few weeks kinda crazy, so I really wanted to jump in and start some of my off unit experiences. I signed up to spend 8-4 on Friday with the wound/ostomy care nurses, and boy was that an experience. We spent about 30 minutes going over the different skin care and wound protocols at the hospital, as well as the different products we use, and then we set off on rounds. We saw all sorts of pressure ulcers, fungal rashes, diabetic ulcers, and even an amputation that had gotten infected when the patient went home and they had to come back and get a wound vac (which was really cool). I have great respect for anyone that can spend their days elbow deep in all sorts of infected ulcerated sores and still come back for more. Our wound care nurses have a passion for what they do, and I am glad because it is not my idea of an awesome career :-). I did learn a TON, and I can now stage, measure, photograph, and document all sorts of wounds and ulcers, can tell a fungal rash from a yeast rash, and know more about the different types of mattresses the hospital has available than I ever thought possible. It was a very good day, and if you have a wound/ostomy nurse at your hospital, I would HIGHLY recommend trying to spend a day with him/her...it really is a great learning experience. After my time with our wound care nurse, I spent a couple of hours in my unit working on the pile of paperwork and education packets that I have that seems to keep growing no matter how quickly I get them done. It was a productive time, as I finally finished the 3" thick PACU study module and test, so I don't have that hanging over my head any more. Within 2 minutes of finishing that, my manager handed me our Cardiovascular Care Manual (with 4 tests of course), and our Cardiovascular Surgery Manual (with 5 more tests)...Will it ever end?????
This post has become another small novel, so I will end here. I am going to do another one in the next day or so though because last night I REALLY started my nursing career, and spent my first 12 hour shift on my unit, with my preceptor, and even took a patient...sort of :-). Check back soon!!
Thursday was Nursing Orientation, and while it was about as exciting as a good swift kick to the head, we did learn LOTS of very useful information. I guess it is better to get all of the housekeeping stuff out of the way first so that when we do start on our units there will be more time for the meat and potatos so to speak. Pharmacy, Laboratory, Pain management, Wound Care, Surgery Services, Respiratory, and the Critical Care Nurse Specialist all came in and talked to us about their roles in the hospital, and our responsibilities to their specific departments. It was a good general overview of the day to day operations, and how they affect the nursing staff. We also got to have a short Graduate Nurse Orientation where they gave us our rounding schedules and talked to us about what was expected of us over the next 10 weeks.
A little bit about our GN program. It is a 10 week program with classroom, unit clinical, and off unit clinical experiences. We have 18 new grads, and 3 people to act as our GN team leaders (One for our Med-Surge nurses, one for the specialties (Ortho, Peds, Oncology, etc.), and one for the critical care areas and the heart hospital). We are signed up to attend basic EKG, 12 lead EKG interpretation, ACLS/PALS, and various other classes depending on our specialty. We have off unit clinical time with PT/OT, Wound and Ostomy Care, Repiratory Therapy, the Diabetes Educator, and some of us spend a day in the OR, a day in the PACU, and a day with the RT learning about Vents. Each week we also have a 4 hour GN enrchment seminar in which different speakers come in and talk to us about stuff like Documentation, Time Management, Medications and Mecication errors, and other things of importance to new grads. All of that, and we still have to do 2-3 shifts a week on our unit with our preceptor, so it will be a busy 10 weeks. At the end of the 10 week new grad internship, we have a skills validation fair and a new grad congratulations luncheon, and then we are sent back to our units to either finish up our unit orientation, or to start with our own patient assignments. Those of us in critical care areas then immediately start with the critical care class and rotation which is very similar to the new grad internship, except with critical care concepts. I will talk about that more once it gets a bit closer.
Most of the GN's have to do 7a-3p Monday through Friday for the first few weeks, but because my orientation will run a bit differently, I am doing 7p-7a 12 hour shits 2 nights a week, and then coming in during the day for the off unit stuff. This is going to make the next few weeks kinda crazy, so I really wanted to jump in and start some of my off unit experiences. I signed up to spend 8-4 on Friday with the wound/ostomy care nurses, and boy was that an experience. We spent about 30 minutes going over the different skin care and wound protocols at the hospital, as well as the different products we use, and then we set off on rounds. We saw all sorts of pressure ulcers, fungal rashes, diabetic ulcers, and even an amputation that had gotten infected when the patient went home and they had to come back and get a wound vac (which was really cool). I have great respect for anyone that can spend their days elbow deep in all sorts of infected ulcerated sores and still come back for more. Our wound care nurses have a passion for what they do, and I am glad because it is not my idea of an awesome career :-). I did learn a TON, and I can now stage, measure, photograph, and document all sorts of wounds and ulcers, can tell a fungal rash from a yeast rash, and know more about the different types of mattresses the hospital has available than I ever thought possible. It was a very good day, and if you have a wound/ostomy nurse at your hospital, I would HIGHLY recommend trying to spend a day with him/her...it really is a great learning experience. After my time with our wound care nurse, I spent a couple of hours in my unit working on the pile of paperwork and education packets that I have that seems to keep growing no matter how quickly I get them done. It was a productive time, as I finally finished the 3" thick PACU study module and test, so I don't have that hanging over my head any more. Within 2 minutes of finishing that, my manager handed me our Cardiovascular Care Manual (with 4 tests of course), and our Cardiovascular Surgery Manual (with 5 more tests)...Will it ever end?????
This post has become another small novel, so I will end here. I am going to do another one in the next day or so though because last night I REALLY started my nursing career, and spent my first 12 hour shift on my unit, with my preceptor, and even took a patient...sort of :-). Check back soon!!
Wednesday, May 13, 2009
What is a graduate nurse to do between graduation and the start of new grad orientation?
Do visions of Margaritas by the pool, relaxing massages and pedicures come to mind????
I wish!!! The last 10 days of my life have been spent cleaning my house, attending an NCLEX review course, and working. I did take the weekend off to run my dogs in a flyball tournament (which we won), but I won't get off on a tangent about my dogs...I promise :-).
The Kaplan NCLEX review was the highlight of my week (not counting the flyball tournament of course), and I think it deserves a bit of a discussion. Many people are torn as to whether or not to attend a review course. They figure heck I just paid $X.XX for 2-4 years of school, why should I shell out 3-600 more for a review course? Well, I can't speak for every review out there, but coming from someone who is an extremely good test taker with a near photographic memory, I wholeheartedly recommend the Kaplan review. Their decision tree model gives you a solid framework for answering questions, and seems to work about 75% of the time even when you know nothing about what they are testing on. That is not to say that you could go in with no knowledge at all and get a 75% just by using the decision tree, but it will definitely up your chances of getting a correct answer. Another great thing about the decision tree is that it gives the non confident test taker a "plan", and therefore a bit of confidence. They also have a great resource in their RN course book...it presents clear and concise information on what I can only assume is a huge part of what we will need to know for NCLEX. The online resources that come with the class have been invaluable to me as well...the qBank and qTrainers supply a large number of high level test questions to practice with (unlike many of the cd's and books that supply mostly knowledge questions). The best part of all is that if you follow their quidelines, and do all of your homework, if you fail the NCLEX, they will refund the cost of your review class...IMO it is overall a great deal. On the downside of the Kaplan review is the 4 days of sitting in a classroom going over test questions with a nurse that has a book with all of the rationales, but the critical thinking skills of a slug. I learned a valuable lesson from that though....I am going to miss some questions because I don't agree with the people making the test (I'm sorry, I will see the possible GI bleed before the incontinence every time). Just because the answer I chose is not the correct answer according to the test, doesn't mean that it is not a viable option. Once I have that RN after my name, it will be my job to determine the "correct" answer for my patient's situation, and as long as I can justify my reasoning and keep my patient safe and alive, it is my call what to do...not some test maker locked in a small windowless room somewhere in eutopia hospital. Bottom line...if you can at all swing it...take the Kaplan review. It is worth every penny.
The other thing taking up my time has been work. I had planned to not work between graduation and the start of the GN program, and hoped that would give me the much needed time to clean my house and get my life in order. Well, it didn't happen that way. Remember my schpeal on teamwork in my first post and how great of a team of nurses we had? Well, somewhere in there I forgot to mention that when you are a part of that team, and things head south you are expected to help out as much as possible. We have had a rough couple of weeks at work, more unstable patients than usual, lots of nurses getting sick, and one nurse deciding to get arrested for stealing drugs (not gonna get too in depth on that...suffice it to say it was a shock and has saddened us all). When census is up and nurses are down, everyone has to chip in, so I spent 3 or 4 nights at work trying to help them keep their heads above water. It is an interesting dynamic there now, as I am not longer just a tech, but I am not quite a nurse yet, so no one is really sure what I can and can't do.
Next week all of that will change, as GN orientation starts on Tuesday. More on that next time!!
Do visions of Margaritas by the pool, relaxing massages and pedicures come to mind????
I wish!!! The last 10 days of my life have been spent cleaning my house, attending an NCLEX review course, and working. I did take the weekend off to run my dogs in a flyball tournament (which we won), but I won't get off on a tangent about my dogs...I promise :-).
The Kaplan NCLEX review was the highlight of my week (not counting the flyball tournament of course), and I think it deserves a bit of a discussion. Many people are torn as to whether or not to attend a review course. They figure heck I just paid $X.XX for 2-4 years of school, why should I shell out 3-600 more for a review course? Well, I can't speak for every review out there, but coming from someone who is an extremely good test taker with a near photographic memory, I wholeheartedly recommend the Kaplan review. Their decision tree model gives you a solid framework for answering questions, and seems to work about 75% of the time even when you know nothing about what they are testing on. That is not to say that you could go in with no knowledge at all and get a 75% just by using the decision tree, but it will definitely up your chances of getting a correct answer. Another great thing about the decision tree is that it gives the non confident test taker a "plan", and therefore a bit of confidence. They also have a great resource in their RN course book...it presents clear and concise information on what I can only assume is a huge part of what we will need to know for NCLEX. The online resources that come with the class have been invaluable to me as well...the qBank and qTrainers supply a large number of high level test questions to practice with (unlike many of the cd's and books that supply mostly knowledge questions). The best part of all is that if you follow their quidelines, and do all of your homework, if you fail the NCLEX, they will refund the cost of your review class...IMO it is overall a great deal. On the downside of the Kaplan review is the 4 days of sitting in a classroom going over test questions with a nurse that has a book with all of the rationales, but the critical thinking skills of a slug. I learned a valuable lesson from that though....I am going to miss some questions because I don't agree with the people making the test (I'm sorry, I will see the possible GI bleed before the incontinence every time). Just because the answer I chose is not the correct answer according to the test, doesn't mean that it is not a viable option. Once I have that RN after my name, it will be my job to determine the "correct" answer for my patient's situation, and as long as I can justify my reasoning and keep my patient safe and alive, it is my call what to do...not some test maker locked in a small windowless room somewhere in eutopia hospital. Bottom line...if you can at all swing it...take the Kaplan review. It is worth every penny.
The other thing taking up my time has been work. I had planned to not work between graduation and the start of the GN program, and hoped that would give me the much needed time to clean my house and get my life in order. Well, it didn't happen that way. Remember my schpeal on teamwork in my first post and how great of a team of nurses we had? Well, somewhere in there I forgot to mention that when you are a part of that team, and things head south you are expected to help out as much as possible. We have had a rough couple of weeks at work, more unstable patients than usual, lots of nurses getting sick, and one nurse deciding to get arrested for stealing drugs (not gonna get too in depth on that...suffice it to say it was a shock and has saddened us all). When census is up and nurses are down, everyone has to chip in, so I spent 3 or 4 nights at work trying to help them keep their heads above water. It is an interesting dynamic there now, as I am not longer just a tech, but I am not quite a nurse yet, so no one is really sure what I can and can't do.
Next week all of that will change, as GN orientation starts on Tuesday. More on that next time!!
Monday, May 4, 2009
I am officially a GN
Hmmmm....where to start.....no time like the present I guess. Today is the first day of the rest of my life. Well, really it is the first day of my life as a nurse. May 3rd 2009 was the day of our pinning ceremony, and I, along with 100 or so of my closest friends, was inducted into the world of nursing with a ceremony that was as rich in tradition as a presidential inauguration, and with all of the fanfair of a superbowl game (airhorns and bodypaint included). All in all it was a very nice ceremony, and we all walked away with roses, hats, lamps, pins and pens, and a rosy outlook on the lives and careers stretching out in our future. I immediately ditched the white uniform, and safely tucked my nursing cap, school pin, and nightingale lamp away so that 20 years from now I can pull them out and reminisce of this special day. I am now a graduate nurse....one measly test away from my RN, and hopefully a long and happy career (notice the positive outlook that I still embody).
Oh yeah...speaking of tests...the NCLEX is looming large in our heads, and first thing this morning my classmates and I attended the orientation for our NCLEX review course. Taking a 180 question practice test was NOT my ideal way of spending the first day after "finishing" school, but it was either now or 2 months from now, and I would much rather get it done and focus on my new career. I now have the rest of the week "off", and we start back with the rest of the review course next Monday. I am planning out my time for the rest of the week, trying to see how many things I can get checked off my todo list while still fitting in some fun time with friends. I have 3 very short weeks before my new career starts with a full time vengeance, and I really want make the best of my last days of freedom.
Now that you know a bit of background, we can get on to the real purpose of this blog...the CSU (insert dramatic piano chords). I have been lucky enough to procure a job as a graduate nurse (the very first I have been told) in a 9 bed cardiovascular surgical intensive care unit. Many of you may know this as the CVICU, others as the CSU, and even occasionally as the CSICU...basically it is the place where any cardiac, thoracic, or vascular surgery patient goes after they are out of the OR. We call ourselves the CSU, but the sign outside the door says that we are the "Cardiovascular Surgical Critical Care Unit"...I guess CSCCU was just too much of a mouthful so they shortened it to CSU. We are located inside a dedicated heart institute and research center, but our building is attached to a regional hospital. Our patients are typically post-op CABG or valve replacement patients, but we also get AAA's, CEA's, Fem-pop's, Thoracotomy's, and unstable CV surgical candidates (Caths gone bad, pacers, cardiac alerts, etc.). We are lucky to have a sister CCU that takes the cardiac medical patients and an interventional unit that takes stable post caths/pacers. We get to see lots of "stuff" on our unit...Swan's, IABP's, VAD's, CRRT, etc. I have been told that it is a golden opportunity for learning, but that I will need to be on my game all the time and do lots of reading and learning on my own time. I don't know if the person that told me that was blowing smoke up my you know what or not, but I get the point...I was given an opportunity that many would kill for (especially in this job market), and I better grab it and hang on with both hands. I will say that the only reason I was even considered for the job was that I have been a tech on this unit for almost a year. I went in and wow'd the staff with my amazing cart stocking, blood sugar checking, and poop cleaning skills, and when the time came they decided that I was a valuable team member (that made me blush), and they wanted to keep me around.
Now let me take a minute to talk about my thoughts on making the all important first job choice. This could be long and drawn out, so if you already have a job, or just plain don't care, skip this paragraph). I have heard many people say that they learned more in their first year of nursing than they did the entire time they were in school. This learning is extremely important because it is literally the foundation that you will use to build your career on. It is a proven fact that what you learn first you learn best, so you might as well put some serious time and effort into the choice of who and what are going to shape your career. I looked at 3 different options for my first job, and made my choice based on what I felt was best for me and my learning. The categories I used to "rate" my options were (in descending order of importance) length of orientation, orientation type, availability of a critical care class (all of my options were critical care based, but this might not apply to you), education opportunities, culture of the unit, location of hospital and lastly pay. Length of orientation for obvious reasons was at the top of my list. My current unit offered me a minimum of 6-9 months with an extension of up to an extra 6 months if I felt I needed it. The other 2 hospitals both had 4-7 month orientations. Orientation type was second on my list. My unit offered me a spot in the hospital graduate nurse program and the critical care course with concurrent one on one preceptorship. One of the other hospitals offered the same arrangement, and their critical care class is said to be the best in the region, but it was not enough to sway my decision. The third hospital had a rotational preceptorship where you were placed with different nurses on a weekly basis. While this might work well for some people, it was not a good fit for me. The critical care class offering was my third category, and while all 3 hospitals offered it, only my first 2 choices integrated it into unit orientation. The third hospital provided it at a cost on your own time. Education opportunities should speak for themselves, and on my list, all 3 hospitals were fairly even. Unit culture was a biggie, and was IMO what ultimately swayed my decision. As a brand new nurse, it is hard enough to get accustomed to your new job roles, so when you thrown in a new hospital with new policies, procedures, and computer systems, it just gets insane. Mix a group of type A personalities, an enclosed space, 9 unstable patients, and a clumsy newbie that can't even find tape in the pyxis...bake for 12 hours in a 370 degree oven, and you have a recipe for disaster. I have noticed that nurses in CSU's tend to be super anal type A with no room for error. Some call them catty, some call them B*&%$'s, and others call them cardiac queens...I can see all of the above, but I can also see that they have the patients best interest at heart, and you would act that way too if you had to answer to the surgeons. Anyways...I got off topic...unit culture...my unit is a very tight nit group of people that works well as a team. When I say team I truly mean team. Many of our nurses have been working together for upwards of ten years, and it shows when the rubber hits the road. Our group knows what the others need almost before it is said. All of the nurses jump in when needed, and there is always someone with a helping hand, listening ear, or even shoulder to cry on. I have worked myself into that culture over the past year, and I can wholeheartedly say that I know for a fact that I will not be eaten alive. I can see where unit nurses get a bad wrap, and I would be scared to start out as a brand new nurse on a brand new unit. These types of nurses don't blindly trust...you have to prove yourself as trustable and that takes time. Patients lives are truly at stake every minute, and that is a lot of responsibility. If CSU nursing is your dream ( or any critical care type nursing for that matter), I urge you to get a job in one of these units as a tech. Work yourself into the culture and give the nurses the opportunity to learn to trust you before they are expected to trust you with a life and death situation. My nurses are the best, and I have 100% confidence that they will do whatever it takes to mold me into the best CSU nurse I can be, and ultimately that is why I made the decision to stay where I am at. Location and pay are pretty self explanatory. Driving an hour or more to work would be no fun, especially with the added stress being a new nurse brings, so please take that into account. Pay is pay...1.00 here, 1.00 there...don't throw away a great work environment with tons of orientation and awesome education opportunities for $0.80 more an hour...trust me it won't be worth it in the end.
I feel like I have written a small novel, and i don't want to bore everyone before we get to the good stuff, so I will stop now. I will try and do some NCLEX review updates next week, and will start full force on May 26th with my first day. In the meantime, a great nurse and awesome friend recommended the following books for me to look over in my "free" time:
Kathy Whites Fast facts for Adult Critical Care
Thelans Critical Care nursing
Marino's The ICU Book
Bojar's Manual of Perioperative care in adult cardiac surgery
Those should keep me in reading materials for the next 2 years or so.
I am truly looking forward to the journey ahead of me. I am excited, anxious, elated, and scared to death all in one. It is a crazy feeling, but I guess I should enjoy it while I can.
Oh yeah...speaking of tests...the NCLEX is looming large in our heads, and first thing this morning my classmates and I attended the orientation for our NCLEX review course. Taking a 180 question practice test was NOT my ideal way of spending the first day after "finishing" school, but it was either now or 2 months from now, and I would much rather get it done and focus on my new career. I now have the rest of the week "off", and we start back with the rest of the review course next Monday. I am planning out my time for the rest of the week, trying to see how many things I can get checked off my todo list while still fitting in some fun time with friends. I have 3 very short weeks before my new career starts with a full time vengeance, and I really want make the best of my last days of freedom.
Now that you know a bit of background, we can get on to the real purpose of this blog...the CSU (insert dramatic piano chords). I have been lucky enough to procure a job as a graduate nurse (the very first I have been told) in a 9 bed cardiovascular surgical intensive care unit. Many of you may know this as the CVICU, others as the CSU, and even occasionally as the CSICU...basically it is the place where any cardiac, thoracic, or vascular surgery patient goes after they are out of the OR. We call ourselves the CSU, but the sign outside the door says that we are the "Cardiovascular Surgical Critical Care Unit"...I guess CSCCU was just too much of a mouthful so they shortened it to CSU. We are located inside a dedicated heart institute and research center, but our building is attached to a regional hospital. Our patients are typically post-op CABG or valve replacement patients, but we also get AAA's, CEA's, Fem-pop's, Thoracotomy's, and unstable CV surgical candidates (Caths gone bad, pacers, cardiac alerts, etc.). We are lucky to have a sister CCU that takes the cardiac medical patients and an interventional unit that takes stable post caths/pacers. We get to see lots of "stuff" on our unit...Swan's, IABP's, VAD's, CRRT, etc. I have been told that it is a golden opportunity for learning, but that I will need to be on my game all the time and do lots of reading and learning on my own time. I don't know if the person that told me that was blowing smoke up my you know what or not, but I get the point...I was given an opportunity that many would kill for (especially in this job market), and I better grab it and hang on with both hands. I will say that the only reason I was even considered for the job was that I have been a tech on this unit for almost a year. I went in and wow'd the staff with my amazing cart stocking, blood sugar checking, and poop cleaning skills, and when the time came they decided that I was a valuable team member (that made me blush), and they wanted to keep me around.
Now let me take a minute to talk about my thoughts on making the all important first job choice. This could be long and drawn out, so if you already have a job, or just plain don't care, skip this paragraph). I have heard many people say that they learned more in their first year of nursing than they did the entire time they were in school. This learning is extremely important because it is literally the foundation that you will use to build your career on. It is a proven fact that what you learn first you learn best, so you might as well put some serious time and effort into the choice of who and what are going to shape your career. I looked at 3 different options for my first job, and made my choice based on what I felt was best for me and my learning. The categories I used to "rate" my options were (in descending order of importance) length of orientation, orientation type, availability of a critical care class (all of my options were critical care based, but this might not apply to you), education opportunities, culture of the unit, location of hospital and lastly pay. Length of orientation for obvious reasons was at the top of my list. My current unit offered me a minimum of 6-9 months with an extension of up to an extra 6 months if I felt I needed it. The other 2 hospitals both had 4-7 month orientations. Orientation type was second on my list. My unit offered me a spot in the hospital graduate nurse program and the critical care course with concurrent one on one preceptorship. One of the other hospitals offered the same arrangement, and their critical care class is said to be the best in the region, but it was not enough to sway my decision. The third hospital had a rotational preceptorship where you were placed with different nurses on a weekly basis. While this might work well for some people, it was not a good fit for me. The critical care class offering was my third category, and while all 3 hospitals offered it, only my first 2 choices integrated it into unit orientation. The third hospital provided it at a cost on your own time. Education opportunities should speak for themselves, and on my list, all 3 hospitals were fairly even. Unit culture was a biggie, and was IMO what ultimately swayed my decision. As a brand new nurse, it is hard enough to get accustomed to your new job roles, so when you thrown in a new hospital with new policies, procedures, and computer systems, it just gets insane. Mix a group of type A personalities, an enclosed space, 9 unstable patients, and a clumsy newbie that can't even find tape in the pyxis...bake for 12 hours in a 370 degree oven, and you have a recipe for disaster. I have noticed that nurses in CSU's tend to be super anal type A with no room for error. Some call them catty, some call them B*&%$'s, and others call them cardiac queens...I can see all of the above, but I can also see that they have the patients best interest at heart, and you would act that way too if you had to answer to the surgeons. Anyways...I got off topic...unit culture...my unit is a very tight nit group of people that works well as a team. When I say team I truly mean team. Many of our nurses have been working together for upwards of ten years, and it shows when the rubber hits the road. Our group knows what the others need almost before it is said. All of the nurses jump in when needed, and there is always someone with a helping hand, listening ear, or even shoulder to cry on. I have worked myself into that culture over the past year, and I can wholeheartedly say that I know for a fact that I will not be eaten alive. I can see where unit nurses get a bad wrap, and I would be scared to start out as a brand new nurse on a brand new unit. These types of nurses don't blindly trust...you have to prove yourself as trustable and that takes time. Patients lives are truly at stake every minute, and that is a lot of responsibility. If CSU nursing is your dream ( or any critical care type nursing for that matter), I urge you to get a job in one of these units as a tech. Work yourself into the culture and give the nurses the opportunity to learn to trust you before they are expected to trust you with a life and death situation. My nurses are the best, and I have 100% confidence that they will do whatever it takes to mold me into the best CSU nurse I can be, and ultimately that is why I made the decision to stay where I am at. Location and pay are pretty self explanatory. Driving an hour or more to work would be no fun, especially with the added stress being a new nurse brings, so please take that into account. Pay is pay...1.00 here, 1.00 there...don't throw away a great work environment with tons of orientation and awesome education opportunities for $0.80 more an hour...trust me it won't be worth it in the end.
I feel like I have written a small novel, and i don't want to bore everyone before we get to the good stuff, so I will stop now. I will try and do some NCLEX review updates next week, and will start full force on May 26th with my first day. In the meantime, a great nurse and awesome friend recommended the following books for me to look over in my "free" time:
Kathy Whites Fast facts for Adult Critical Care
Thelans Critical Care nursing
Marino's The ICU Book
Bojar's Manual of Perioperative care in adult cardiac surgery
Those should keep me in reading materials for the next 2 years or so.
I am truly looking forward to the journey ahead of me. I am excited, anxious, elated, and scared to death all in one. It is a crazy feeling, but I guess I should enjoy it while I can.
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