Nurse on the Run

Annnd it’s Thursday of Nurses Week!  You know what the best part of Nurses Week is?  Not working!  I wrapped up four shifts in a row yesterday, took a nap, and then managed to flip my schedule back to normal in one day and woke up at 8:30am this morning.  If you know me, you know this is not normal, but I made it and now I have eight nights off.

Eight nights off.  Without taking a single day of vacation!  One of the perks of nursing, most definitely.  I was supposed to run a relay race this weekend (Ragnar Cape Cod), but my back is still not agreeing with me (one day at a time…), so I’m out.  Instead I’ll be giving my back a rest from running and from nursing since moving patients, doing wound care, and drawing labs, etc etc probably doesn’t help.  Fingers crossed.

For today’s Nurses Week post, I figured I’d do something along the lines of “A Day in the Life” to try and give you an idea of what it might be like to work as a hospital nurse.  The problem with this is that it won’t fully capture everything that we do.  Also, we have many options for the different kinds of patients we have.  On a given day, I can have any of the following combinations:

• 1:1 assignment with an ICU patient
• ICU patient with a “walkie-talkie” small burn patient (meaning they’re pretty much fine outside of the burn)
• Multiple adult patients with smaller burns, usually up to four patients
• Pediatric burn patients
• Medical/surgical overflow patients

A day in the life with each of these groups is a little different, but I’ll try and give you an idea!  Also, I’ve been on night shift for about the past four months, so I’ll talk about that.  Day shift is definitely different.  So here we go.

7:15pm

I usually arrive at work between 7:15-7:22 (on the dot…) and get my scrubs from our scrub machine, as we wear “clean” scrubs.  It’s nice in that I don’t have to wash my own scrubs, but sometimes the machine runs out of smalls.  Then I wear mediums.  Or extra extra larges:

Anyway, I change, put my food in the refrigerator, and head out onto the unit to find out what my assignment is.  I get my room assignments, then grab a piece of paper to put patient ID stickers and organize my paper to get report.  (Despite all the crazy technology floating around, I don’t know a single nurse who doesn’t take report on a piece of paper to carry around in their pocket.)

7:30-8pm

This is the time when day shift and night shift overlap, so that’s when report is given!  If you’re a family member, please don’t call during this time.    (This varies between all hospitals, so don’t go by that!)  We get report from the previous shift, reviewing the burn sites, pain medication required for dressing changes and breakthrough pain, then go through a systems reviews (neuro, respiratory, cardiovascular, GI, GU).  Important things mentioned include the pain medication required and when the patient last had a bowel movement.  (Nursing is so glamorous…)

After report, I log into the computer and do a twelve hour order check which I sign off, which basically reviews the patient’s orders to make sure nothing slips through the cracks.  I’ll also look at labs, review the doctor’s notes from the day, and the nursing burn care note.  At this point I’ll review the medications I need to give during the shift and make a checklist of things I need to do for each patient…noting what time labs need to be drawn, if I need to give any electrolyte replacements, hang fluids at midnight, etc.  Any of the tasks that need to go down.  Basically organizing my shift so I have an idea of what to expect, especially if things start to get a little crazy.

8pm – ???

So this is when things start to change between all the assignments.  If I have multiple patients, I’ll start going patient to patient (prioritized in my mind beforehand) to take vital signs and do assessments.  While doing this, we do mental checks in the room looking for emergency equipment (just in case…), assess pain, always ask about the last bowel movement (don’t forget!), and see if the patient needs anything (water, more Ensure to drink!).  With my patients who are more walkie-talkie (just what it sounds like…they can walk around, talk, usually have a smaller burn), I work with them to determine what time they want to do their dressing changes, which we do in the rooms at night.  I try to get these done on the earlier side (hopefully before 11pm, if possible) so the patients can attempt to get some sleep at night.

If I have an ICU patient, the idea is the same, but there are a few more steps involved.  Assessments are a little more intense as we check alarm settings on the monitor, zero arterial lines and CVPs, check the settings on the ventilator, do oral care and suction for secretions, check feeding tube placement and residuals, empty Foley catheters to check urine output.  I trace back the lines that the patient has to see what’s going through each one.  Check a blood glucose if the patient is on an insulin drip.  Neuro checks.  Blood gas at some point for the ventilated patients.  Each nurse has their own little system to do everything that needs to be done, and you get a routine down to make sure you hit everything.  Definitely not an all inclusive list!  Patients may also be on CVVHD (constant dialysis), receive bedside dialysis, have more intense cardiac monitoring requiring calibration, among whatever other monitoring you could think of.

After assessment and vital signs are done, it’s usually time to medicate people as many standard medication (vitamin C, stool softeners [again with the poop…]) are scheduled for 9pm.  Anyone who needs premedication for burn care will receive medication about an hour before the planned dressing change to allow for it to work…just like when you take Tylenol for a headache, it needs time to kick in!  During time time I’ll set up what will be needed for the dressing change so I’m all set to go when the pain medication is kicking in.  At this point it’s basically going from room to room as necessary to do dressing changes.

The same things apply to the pediatric burn patients, except we’re really on top of their intake and output.  Everything is weight based, and we keep track of everything that goes in the patient and everything that comes out.  Diapers are weighed  Since kids can’t necessarily tell you when things are going south, we use these as indicators as how the patient is doing.  Many of the kids have feeding tubes because getting the proper nutrition is so important, and kiddies don’t necessarily want to eat if they’re in pain or in a new environment (or they just don’t like the Ensure we’re giving them).

burn care

So what exactly does burn care entail?  At night, we do dressing changes at the bedside.  During the day, patients who are able to walk go into our shower room, and other patients who can’t shower but are still stable will go into “the tank.”  More therapeutically called the hydrotherapy room, “the tank” looks like this: 

(Thank you internet, not my actual unit!)

Big burns are generally washed at the bedside due to being hooked up to ventilators and/or a ton of monitors.  But the idea is still the same.

Dressings are cut down and removed, and burns are washed with a certain soap.  We debride (remove…) any skin that is coming off, which is how the burn heals, by slowly removing the dead skin until healthy skin comes back through.  If this isn’t happening on its own, patients will go to surgery for skin grafts.  Once the burns are cleaned and debrided as much as possible (or as much as the patient can tolerate), topicals are applied based on where the burn is in the healing process, then they’re covered and wrapped.  IV pain medication is often given throughout this process since it’s very, very painful…I’ve never experienced it myself, but I wouldn’t wish it on anyone.  Depending on the size of the burn and the patient’s tolerance, this process can be quick (taking more time to set up and clean up than actually change the dressing!) or could be an hour.  These types of smaller burns are usually just done by one person unless help is needed, in which case you coordinate with a tech or another nurse.

back to the routine

If the patient is an ICU patient, certain things need to be done every hour.  Vital signs, ventilator reports, and intake and output are recorded every hour.  (Constantly monitored, recorded every hour along with any important changes between hours.)  Urine is dumped and recorded, blood glucose checked, insulin titrated per protocol.  Turn patient to prevent pressure ulcers.

Of course, it’s not necessarily as smooth as it might sound because a ventilator may alarm, blood pressure alarms might go off, patient might slide down in bed and need to be repositioned, etc etc etc.  Troubleshooting and problem solving are ongoing, and I’ve learned not to freak out about the tiniest alarm…an oxygen saturation problem is usually a result of the sensor falling off the finger/toe/forehead, so that’s one of the first things I check before freaking out.  Patients may also have bowel movements at any given time (it’s an important function…), so those need to be cleaned.  Basically, you have hourly things to do yet are always monitoring and thinking about how to help the patient.

12pm – 5am-ish

Vital signs are done on most other patients every four hours, so come midnight those are done on all patients.  At this point (or earlier), I give the patient a head’s up if I have to draw blood on them in the morning since I wouldn’t want to be woken up at 5am with someone telling me that they need to poke me with a needle.  Otherwise, if they’re perfectly stable, I tell them I’ll try to let them sleep (sleep is much harder to come by in a hospital than you would think…) and to call me if they need anything in the night.  I’ll stick my head in the room to check on them throughout the night.  Patients will usually call for pain medicine or water or a blanket.  But you never know.  I’ve hunted down wallets at 2am.  Had patients freak out about their lack of a bowel movement at 3am.  It always something.

Notes are written on the patients detailing their burn care…what medication they received, what the burn location is and what it looks like, if it was debrided, what topicals are applied, the dressings applied, and how the patient tolerated it.  This is a good reference for the next shift and to see how the burn is evolving.

With the kids, I’m pretty good at doing vital signs and checking as necessary without actually waking them, which is a fine art in moving around in the dark.

For burn care on ICU patients, the time when we do it varies.  I try to get it done on the earlier side (11pm?  Midnight?) to allow the patient to “rest” like a normal person, but often it’s done at 2am.  This often requires at least one other person to help you, if not more.  I’ve been in a room with six people changing one patient’s dressings.  Two hour dressing change?  Been there.  (I think the longest one I’ve done took 2.5 hours…that will make the shift go fast!)  This is just like doing dressing changes on the other patients, except on a larger scale and they can’t necessarily help to hold their arm up.  We give lots of pain medication.  Team work is key.

Throughout the night, the same hourly monitoring applies to the ICU patients (vital signs, check urine, ventilator).  We do some things every four hours and as needed (oral care, suction trach/ET tube, rezero arterial line/CVP, check feeding tube placement and residuals).  Ventilator settings may be changed and blood gases may be done.  At night, were also responsible for all the daily switching of bags of saline, feeding tubes, suction containers, etc etc.  If a patient is having their arterial line or central line changed the next day, we set up the lines for the day shift.  Behind the scenes kinds of things.  Daily labs are sent a little on the earlier side (3am?  4am?) for these patients.  I love arterial lines!

This is also the time when I eat “lunch.”  Yep, a full meal at 2am.  Usually with coffee.

5am – 7:30am

Around 5am, the shift starts to pick up again for patients who I let sleep a little.  More vital signs, labs drawn on patients who have them ordered.  Some patients shower early in the morning for the attending physicians to see them right away (either for discharge or to decide if they’re going to surgery later in the week), so they’ll wake up early and shower.  Otherwise we wrap up them for the shift.  The residents and fellow come in at 6am and some new orders go in based on lab results or whatever else is needed.  Pre-breakfast blood sugars are taken.  Foley bags are emptied of urine so everything is set for the next shift.

7:30am – 8am

Report is given!  Hooray!  If you’re lucky, the same nurse who had the patient the day before will be back, which means that report usually just involves updates from what happened the night before or what was decided in morning rounds, as well as any reminders that might be important.  Otherwise, report is the same as I said above.  Then it’s time to go home!

throughout the shift

I don’t know how controlled all of this sounds, but each shift is different.  It depends on what types of patients you have, how stable they are, what issues arise throughout the night.  Otherwise, new admissions may come at any time, which involves orientating them to the unit (it’s a lot of information ranging from where the bathroom is to an idea of how the day goes to the importance of nutrition, etc etc), vital signs/assessment just like any other patient, admission history, and initial burn care.  If it’s a “big admission,” such as a critical patient with a large burn, then it’s a big team effort to get the patient in and set up and monitored.

Medications are administered as ordered (pain medication as needed, of course!)…some medications are due at 3am, although I try to get them scheduled so I’m not giving vitamin C at this time.  Antibiotics may been to be hung though, so I try not to totally frighten patients when I wake them to do this.

Basically, the key is that anything can happen.  The basic things that you do every day are present (vital signs, assessments, burn care…and that’s just the beginning), and then you roll with the punches as they come.

that’s a wrap

As I said before, this certainly doesn’t fully describe what it’s like to be a hospital nurse, but hopefully it gives you an idea!  I don’t know what it’s like to work in an office or even just 9-5.  Most people will never work overnight in their entire career.  Hopefully this gives you a glimpse into what it’s like to be a nurse (did I mention the bowel movements yet?) and an idea of what my night is like while you’re sleeping!

Let me know if you have any questions, and if you’re a nurse as well, I’d be interested in hearing how your work is the same and/or different than mine!