Posted in Tips and Advice

If you’ve been listening to my podcast you may have already heard the Big News that I made a huge change in my professional career and went from Medical Intensive Care to PACU nursing.. There were a lot of reasons for this change and overall it has been a very positive experience. So, I thought I’d write today about all the positive aspects of this huge change, because, let’s face it…change can be scary. But, with a focus on the positive, it certainly doesn’t have to be!

All the reasons why I changed to PACU nursing

Making such a large change was a huge decision for me and one that I fretted over for MONTHS. There is definitely a benefit in being able to go to your job knowing what you need to know and feeling like you can handle pretty much anything that comes your way. You know the people, you know the routines, you know the quirks of the unit, you know the docs, you know the processes…to go from knowing to NOT knowing is scary as heck! But when an opportunity in the PACU popped up, I jumped at it…here’s why:

The schedule

As many of you know (because I grumble about it a lot on the podcast!), I’m currently in graduate school getting my MSN in nursing education. It’s not as all-consuming as undergrad, but it’s still difficult with a full-time work schedule, blog, podcast and all the other things I do to mentor nursing students. I was killing myself working full time, going to school full time (three graduate level courses is no joke!) and trying to run Straight A Nursing. The first person who says, “you only work three days a week” is getting a fork in the eye…just try me (joking…sort of!). Three days in that environment is absolutely physically, emotionally and mentally crushing. I found that I barely had the energy to give anything to you guys (sorry!). Plus, I called in regularly to see if the unit was overstaffed so I could volunteer to get called off. I was exhausted ALL the time, and to be honest, pretty darn cranky.

So, when the PACU job came up and I saw that it was a per diem job…I did a little happy dance. The schedule is MUCH better…I put in my availability and if they need me, they schedule me. I am only committed to working two eight-hour shifts a week and the hours are varied…I might go in at 1130, 1430, 1200…it’s great! I can do things in the morning when I’m full of sass, and then go to work for a few hours. It’s a win-win-win.

The turnover

Working in the MICU means working with the same patient(s) for 12 hours. This is great if you like your patient or have a really good or interesting assignment…but what if it’s a rough one? What if it’s a grown man with the strength of six oxen who has hepatic encephalopathy, is on lactulose (look it up if you don’t know what it does), who is constantly pulling off his leads, taking off his oxygen and trying to get out of bed with an art line, foley cath, central line and vasoactive gtts running? Not so fun. Not so fun at all.

With PACU nursing, you have your patients for anywhere from 30 minutes to 2-ish hours for the most part. Most of the time, about 75 minutes seems about average. So, even if your patient is really challenging, demanding, or even annoying…they’re gone before your frustrations can start to mount up. Sure, people can be acutely confused in the PACU…they’re coming off anesthesia after all and in some cases getting a butt-ton of pain meds. But they’re usually still groggy enough from surgery that the situation isn’t too terribly challenging (of course, there are exceptions…big back surgeries being one…those patients are in A TON of pain and need a lot of TLC).

Dealing with challenging patients (and even families) in the MICU was emotionally draining for me and I just found I didn’t have the energy to bounce back like I used to. Now I find that I enjoy my interactions with patients, short as they are. No matter how challenging a situation may be, it’s short-lived…and at this point in my career that is a-okay with me. And, it may be my new-ness speaking, but overall I find that patients are so relieved that surgery is over that they are generally so appreciative and kind. Its really pretty refreshing, to be honest and one of my favorite aspects of PACU nursing..

The pace

The pace in the MICU is largely dictated by your patient assignment. Do you have two vented patients from the long-term care facility who are there for IV antibiotics, or do you have a super-sick septic patient going on CRRT?

In the PACU, I’ve found the pacing to be much less intense and more or less consistent. We have one or two patients at a time, recover them from their anesthesia, then either send them to the discharge recovery room or up to their rooms. By the time you get back, you may have a few minutes downtime, or you may be getting another patient…and the cycle continues like this for the whole shift. To me, it’s a more predictable pacing (with exceptions, of course), but I have found that even though I’m busy all day, I’m not RACING to get a mountain of things done, and charted, by the end of my shift. Working day shift in the MICU, I felt like each and every day was a challenge…I had SO MUCH to do for each patient that I literally felt like I was running a race. If someone from social work or some other team needed to talk to me, I literally would say, “Let’s walk and talk” because I Did Not Have Time to Pause for Even One Moment. When you’re responsible for the care of two critically ill patients, every second counts. Trust me on this one.

Now, of course, the flip side of this is taking care of two patients who aren’t necessarily critically ill, but they’re in the unit because they’re ventilator dependent. These patients may not be all that busy and those days would just drag on and on and on and on (12-hours can be a very, very long time).. So, PACU nursing is a really nice medium…it’s busy but not “ohmygod I’m racing around the unit like my pants are on fire” kind of busy…and it’s not “ohmygod, how many hours are left?” kind of mundane. It’s really kind of perfect for me right now and I’m definitely appreciating the change of pace.

The scope of PACU nursing

Working with critically ill patients is a huge, ginormous, gargantuan responsibility. And, as the nurse, it is your job to solve ALL their problems and prevent ALL the problems they could potentially have. To say it is a daunting task is an understatement. Remember that race I mentioned? This is one of the things that make it so challenging. Now, before someone sends me a “friendly reminder” that nurses do not diagnose or prescribe…yes, I am aware of that. When I say the nurse solves the patients problems I mean that s/he implements the ordered/prescribed interventions AND must be diligently aware of any problems the patient is having so the MD can be notified.

And then there’s the prevention part. Nurses spend a lot of their time preventing the patients from developing MORE problems as a result of their illness or situation. Preventing pressure ulcer, preventing skin breakdown, preventing ventilator acquired pneumonia, preventing regular ol’ pneumonia, preventing acute delirium, preventing muscle atrophy or contracture, preventing infection…the list goes on and on (and on!).

In the good ol’ PACU, I have a much more narrow focus when recovering my patients. Mainly…is their airway patent and are they breathing? Next is hemodynamics…what’s their heart rate…what’s their blood pressure…are they perfusing? Ok, good. And then, of course we watch for complications associated with their specific surgery (huge learning curve with this one…learning about all the different procedures has made YouTube my new BFF). And, lastly…there’s pain. In PACU nursing, we treat pain very well, but there’s a careful balance between pain intervention and respiratory depression, which takes us back to…you guessed it… airway!

Of course, I’m not going to say we don’t work to prevent complications…of course we do. But the patients aren’t typically under my care long enough to have pressure associated injury or develop hospital acquired pneumonia. They certainly can be confused, but it’s usually because of anesthesia, not because acute delirium has set in. Overall, with PACU nursing, I am enjoying having this laser-beam focus on the care I provide my patients. I feel a LOT less stressed overall and this, my friends, is a Very Good Thing.

The charting

Ohmygoshcanwetalkaboutcharting? If you’re a student, you might not yet realize the MOUNTAIN of charting an RN must do each shift. Is there something larger than a mountain? If so, then that’s what it is. Especially in the ICU where there is SO MUCH to monitor, assess, administer, evaluate, and re-assess each shift. I once had a very easy assignment (translation…I was bored), so I took to counting how many data elements I HAD to chart in a 12-hour shift for one patient. The count was OVER ONE THOUSAND ITEMS when I gave up…and this was on a not-so-sick patient who was basically just there waiting to be transferred out. I don’t even know how many data points must be recorded for an actual critically ill patient…and I don’t think I want to know.

Much like the assessments and interventions being laser-focused in the PACU, so is the charting. I chart on things relevant to that patient’s surgery along with the basics and core-measures like anti-thrombotic interventions, pain, vital signs, communication with the physicians and any abnormal findings. I can whip through a patient’s initial charting along with their care plan and education in 5 minutes or less (provided there are no distractions). It’s magical.

The elephant in the room

Ok, let’s talk about it. Family. I know I know I know what you are thinking. As a student you might not be able to imagine that family members could be anything but kind, sympathetic, worried, stressed, fragile bystanders. And some of them are. And some of them are so not. You will soon discover that having family members present almost always increases your workload. Not only are you managing the patient, you’re now managing and caring for the family as well. Answering their questions, addressing their concerns, fetching them water or coffee, telling them the same things over and over, instructing them not to stimulate the patient as they continue to stimulate the patient, and deflect their many many requests for things that derail you from your patient’s acute priorities.

In the PACU, we only allow 1-2 visitors at a time, and typically only after the patients have been in the PACU for awhile, their pain is manageable and their pressing needs have been met. Don’t get me wrong, family presence has been shown to be beneficial from the patient and family’s point of view. And while some family members are absolutely delightful, the truth is…it often does add to the primary RN’s workload and stress. Even family members with the very best intentions will interrupt, ask questions, and make requests as you are thinking through complex problems, calculating drug dosages, programming the pumps or titrating medications. Setting boundaries is important and can always be approached in the “for your loved one’s safety and to ensure he/she gets the best care…” type of framework.

Overall, I love love love it!

I’ve been in PACU for a little over a month and I have to say I am really really really enjoying it. I love the short but focused interactions I have with patients, I love the quick pace and fast turnarounds. I really am digging my awesome coworkers. And I am absolutely LOOOOOVING my per-diem status. Once graduate school picks up again in the Fall, I’ll be working two 8-hr shifts a week and able to focus more attention on my studies so I can become an even more awesome educator for you guys! It’s a win-win-win-win-win!

If you’re a student exploring all the choices available to you, or an RN thinking about a change, I can confidently say that PACU nursing is definitely worth looking into. Got questions? Or, if you are an experienced PACU nurse…tell me your best tips and advice in the comments below 🙂

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