Am I a safe nurse? (LONG)

  1. I am a new grad nurse just off orientation (4 days) after 4 weeks with a preceptor at a rehab hospital. I am on a general musculoskeletal/neuro floor and we see a lot of stable post-op patients. One of my patients was admitted with a s/p aortic valve replacement and had a pacer put in for paroxymal a-fib. He was in sinus rythm when he came and up until yesterday there had been no issues. He was taking atenolol 25mg tid and lasix 20mg QD. Three days ago, I held his 1300 dose of atenolol for a bp 92/55 but his pulse was 94. There were no parameters listed so I paged the MD asking for parameters. I never heard back and got busy and well, I just didn't get around to follow-up before the end of the shift. The next few days there were no issues with his BP so I didn't follow-up on the parameter page I had sent the MD. My bad, I know.

    Yesterday, I took the patients BP and pulse prior to his 1300 dose of atenolol. He pulse felt slightly irregular so I took an apical pulse and got 104 and thought I heard some extra heart sounds. Being a new nurse and not having much experience with cardiac patients, I'm not sure about what I'm hearing. I paged the MD with this info. She came to the floor, saw the patient and asked me if I had him to hold his breath...no, was he having pain...he asked me for pain med shortly thereafter. She said he is fine, his heart rate has been in the 100s. The fact that he was in pain could have caused an elevation and the lung sounds could have gotten in the way of what I was hearing. I felt really dumb.

    Today the patient was due to be discharged. The MD verbally told me the parameters she gave to the patient was to not take the atenolol if SBP was below 100 and to call his MD. I reinforced this teaching with the patient and wrote it down for him on the teaching sheets we sent with patient and put in the chart.

    He was due to go home at 1000, family called stating they couldn't come until 1230. At 1220, patient is asking for some pain med so I bring him 1300 meds, too, except the atenolol, because the MD has him starting 50mg BID when he leaves. At 1315, patient was still there and c/o funny feeling in his chest. I took his BP and apical pulse and his pulse was 125 and irregular.

    I paged the MD who ordered an EKG. EKG showed patient was in rapid a-fib. Nurse manager chewed me out in front of charge nurse, peers, PT/OT and patients for not giving atenolol two days ago and the 1300 dose today when no parameters were written and somehow felt that I was also responsible for the other nurses over the weekend who did not give the atenolol for SBP below 100, telling me that this is what caused his current state. I feel awful and worry that I am not a safe nurse because before today, I thought atenolol was a medication that was primarily used to control BP, not heart rate.

    I know next time to alway get parameters and to trust my gut. The other thing I didn't do was document the conversation that I had with the MD yesterday about what I thought was my "foolish" assessment.

    One dose of his atenolol was held by me 3 days ago, and prior to that the weekend nurses held 2 or three doses. Could all of this contributed to this situation? I feel like I really screwed up bad and I need to know if I should feel this way. I worry that after the way my nurse manager spoke to me today I might be getting fired. Thats not the only thing that happened this week where I've screwed up. I had a patient that was getting discharged and the patient left before the MD saw her and there was no order written. MD came down 2 hours after the patient was on the board to leave. I finished my teaching with her, case manager went in, patient left. I did not tell her she could go, nor did I know she was leaving, but I was blamed because there was no order written. I definately feel like I am going to lose my job. 2 big mistakes in 4 days. Not off to a good start.

    Thanks for listening. I know as a new nurse I am still learning a lot. But I don't want my lack of knowledge to harm someone and I am worried that it already has.
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  2. 9 Comments

  3. by   steelcityrn
    Just so you know, all nurses can have a bad week. When you are a new nurse, there is going to be some mistakes. I see physicians make them also. You will always be learning as a nurse. I feel you are a safe nurse because you have a conscience. It comes across very clear. Do not beat yourself up. Keep you head high, explain what you did, do not speak for anyone else. Let them do the dirty work of finding out all that happened. Do not talk about it with anyone but your managers. And they were very very wrong to say anything about you in front of other co-workers. Best of luck.
  4. by   deeDawntee
    I am sooo mad at the way your nurse manager handled that situation and I think you should tell her so...to "publicly" humiliate you is a terrible way to manage.

    I don't know if you could have handled this situation differently or not. It seems as if the communication is sorely missing at your place of work. It sounds to me that you made the right moves and was asking the right questions. Did you get your charge nurse involved in your decision making? I still do that, we all do, if we aren't sure what to do and ALWAYS document your actions, so that you are covered, especially when a Doc doesn't return your call.

    I also don't understand why the pacer wasn't kicking in and keeping the guy out of a fib. Perhaps it wasn't set correctly and needed to be interrogated. I have NEVER heard of Atenolol being prescribed as a drug to prevent a fib, it is used for HTN and to reduce cardiac workload especially in patients with angina. Beta blockers are ordinarily held for HR <60 and SBP <100. So, I think you did the right thing and as long as you documented the reason, you are OK.
    There is no way that missing a dose or even 3 is responsible for that pt's atrial fib. I think it is a good think it happened that way. It sounds to me that the patient absolutely should have been telemetry monitored and it is the Docs negligence that caused his problems and not yours.

    Get out of that place, my dear. It is an unsafe work place. You have a crappy manager who is willing to throw you to the wolves and not train you and not be willing to take responsibility that the patient did not belong there.
  5. by   nursecompassion
    Sometimes I find myself wondering the same thing, but I don't think it's just among the new grads on my unit. I think the patients are sicker with multiple problems and pt load is to much. I've already heard from nurses on my unit. I find myself going into my patients rooms, giving care and have to look at my flow sheet to recall why they're even here! I feel like I never have time to even take a look in their charts at their history. It feels really crazy some days, I hope that it all "comes together" sooner than later! Hope everyone hangs in there and good luck on your orientation!

    jules:spin::spin:
  6. by   sleepyjane
    Thanks for the words of encouragement. Even thought I am a new nurse, I expect to know everything and when I don't I tend to beat myself up relentlessly. My preceptors last day working a regular schedule was my last day of orientation so I need to turn to other nurses for support. They are all wonderful and encouraging and entertain all of my "stupid" questions. But they are all so busy and sometimes I feel like there is no one to turn to when I have a question. Its definately sink or swim, and I don't know if its like this everywhere. I love the patients that I have, but I am having a hard time adjusting...I still don't even know where to find supplies half the time.

    Anyway, I am hoping it all comes together soon. I am good about remembering primary dx, but comorbities escape me half the time and when I am questioned, I stammer. Se la vie...I hope I get good at this eventually...Thanks again!
  7. by   canoehead
    I think both situations were handled unfairly. If someone leaves without telling you, and you didn't tell them they were free to go, how is that your fault? That's leaving AMA in my book, unless I am missing something.

    I agree that patient should have been on telemetry. It sounds like he might have been in and out of afib long before his discharge date. If the atenolol was intended to prevent that the doc needed to make that clear, since the med was held for low BP when it was the pulse rate she was treating (??) It sounds like he needed something less effective on BP and more on heart rate. Anyway, on the last day he went into afib 15 minutes after the med was due- sheesh it wasn't even late yet...OK, so some more pointed questions might have been asked by someone with more experience, but apparently even the doc wasn't on to this patient's developing issues. Cut yourself some slack.

    If they fire you, it's a job you are well rid of. they should do some teaching, and work on communication among the entire staff, not just you.
  8. by   SuesquatchRN
    Sounds like the doc should be educating the nurses properly.

    I'm sorry. Just hang in there.
  9. by   RN1989
    There are things I see wrong from all sides of your story so I'm not going to get into that. I will say - CYA. Chart, chart, chart. So many people put charting low on the priority list, especially when you are charting by exception. But charting can save you a good deal of the time. Learn from what happened on what you can improve on and protect yourself because no one else will.
  10. by   David's Harp
    Well, coming from someone still on orientation, I think you're a safe nurse in an unsafe place. And there's no worse way for a manager to handle things than to chew you out in front of an audience like that. Okay, I'm going to need some atenolol if I dwell on that too much...

    It sounds like you have some good co-workers if they're open to questions. Can you stand back from the situation and extrapolate some guiding principles from it? Someone else mentioned documentation. Some docs need to be directly asked, "What are we treating here?" Some docs need a few pages before they'll answer, even if it's for genuine reasons. Does your institution have a Rapid Response Team, supposing your guy's rate really got out of control and you heard nothing from the MD? I'm also wondering if that was the right floor for a fresh pacer insertion & valve replacement. Are you guys put through any Dysrhythmia training? Is this a typical patient for the floor?

    Again, this is speaking from little experience (7/12 wks of orientation - I can't be flamed here until week 13...).

    -Kevin
  11. by   patwil73
    First off I want to say that every mistake is a golden opportunity to learn, as the "terror" tends to help reinforce the teaching. That being said, please don't beat yourself up over your actions - the mere fact you are here asking questions says you are a safe nurse.

    Quote from sleepyjane
    I am a new grad nurse just off orientation (4 days) after 4 weeks with a preceptor at a rehab hospital. I am on a general musculoskeletal/neuro floor and we see a lot of stable post-op patients. One of my patients was admitted with a s/p aortic valve replacement and had a pacer put in for paroxymal a-fib. He was in sinus rythm when he came and up until yesterday there had been no issues. He was taking atenolol 25mg tid and lasix 20mg QD. Three days ago, I held his 1300 dose of atenolol for a bp 92/55 but his pulse was 94. There were no parameters listed so I paged the MD asking for parameters. I never heard back and got busy and well, I just didn't get around to follow-up before the end of the shift. The next few days there were no issues with his BP so I didn't follow-up on the parameter page I had sent the MD. My bad, I know.
    Some people have pointed out that your facility appears unsafe - I would like to echo this. A general musko/skeletal - neuro floor is no place for a s/p aortic valve replacement patient. The fact that he had his valve replaced says he is not your typical stable surgical patient, and the addition of a pacemaker (which is not often used with a-fib) adds another layer of difficulty (as it usually indicates a low HR from medications.

    That being said, you should not hold beta-blockers (which atenolol is one) without a doctor's order:

    Black Box Warning - Atenolol

    Patients with coronary artery disease, who are being treated with atenolol, should be advised against abrupt discontinuation of therapy. Severe exacerbation of angina and the occurrence of myocardial infarction and ventricular arrhythmias have been reported in angina patients following the abrupt discontinuation of therapy with beta blockers. The last two complications may occur with or without preceding exacerbation of the angina pectoris. As with other beta blockers, when discontinuation of atenolol is planned, the patients should be carefully observed and advised to limit physical activity to a minimum. If the angina worsens or acute coronary insufficiency develops, it is recommended that atenolol be promptly reinstituted, at least temporarily. Because coronary artery disease is common and may be unrecognized, it may be prudent not to discontinue atenolol therapy abruptly even in patients treated only for hypertension .

    Even if you are holding for a low dose, if their is no parameters and the next nurse goes off what you report (held due to this) and she holds, and the next holds, we have abrupt discontinuation - or at least the possibility of such. If the doctor does not call back, you have to keep paging - write it down so you don't forget and tell your charge also, so you have a backup.

    Quote from sleepyjane
    Yesterday, I took the patients BP and pulse prior to his 1300 dose of atenolol. He pulse felt slightly irregular so I took an apical pulse and got 104 and thought I heard some extra heart sounds. Being a new nurse and not having much experience with cardiac patients, I'm not sure about what I'm hearing. I paged the MD with this info. She came to the floor, saw the patient and asked me if I had him to hold his breath...no, was he having pain...he asked me for pain med shortly thereafter. She said he is fine, his heart rate has been in the 100s. The fact that he was in pain could have caused an elevation and the lung sounds could have gotten in the way of what I was hearing. I felt really dumb.
    Please don't feel dumb. Your concern is valid. The doctor sounds good though, like she did some teaching to go along with your concern - now you know something you didn't before.

    Quote from sleepyjane
    Today the patient was due to be discharged. The MD verbally told me the parameters she gave to the patient was to not take the atenolol if SBP was below 100 and to call his MD. I reinforced this teaching with the patient and wrote it down for him on the teaching sheets we sent with patient and put in the chart.
    Did the doctor write down his parameters - if not, he is at fault here. Doctors should always write down what they want the patient to do. However, after he told you, you should also document in a chart note. Any communication must be documented - it is the safest thing for both you and the patient.

    Quote from sleepyjane
    He was due to go home at 1000, family called stating they couldn't come until 1230. At 1220, patient is asking for some pain med so I bring him 1300 meds, too, except the atenolol, because the MD has him starting 50mg BID when he leaves. At 1315, patient was still there and c/o funny feeling in his chest. I took his BP and apical pulse and his pulse was 125 and irregular.
    I understand your thinking here, but consider - he was on 25 mg TID right? So in the morning around 0600 he got 25 mg. If he was going home on 50 mg BID he would probably start the dose at night so giving him the 1300 dose of 25mg would have made 50mg for the morning.

    Quote from sleepyjane
    I paged the MD who ordered an EKG. EKG showed patient was in rapid a-fib. Nurse manager chewed me out in front of charge nurse, peers, PT/OT and patients for not giving atenolol two days ago and the 1300 dose today when no parameters were written and somehow felt that I was also responsible for the other nurses over the weekend who did not give the atenolol for SBP below 100, telling me that this is what caused his current state. I feel awful and worry that I am not a safe nurse because before today, I thought atenolol was a medication that was primarily used to control BP, not heart rate.
    Atenolol is a beta blocker which can be used to help control rate in dysrhythmias. Offical uses are for acute MI, agina, and HTN.

    The nurse manager should never speak to anyone like that - in front of others or not. If she had a concern it should always be addressed in private. You might want to see HR about this - or your union if you have one.

    Quote from sleepyjane
    I know next time to alway get parameters and to trust my gut. The other thing I didn't do was document the conversation that I had with the MD yesterday about what I thought was my "foolish" assessment.
    And you have learned two very valuable lessons, with minimal harm to the patient. We all make mistakes, hopefully we will continue to learn from them.

    Quote from sleepyjane
    One dose of his atenolol was held by me 3 days ago, and prior to that the weekend nurses held 2 or three doses. Could all of this contributed to this situation?
    Although you might not want to hear it, the answer is yes. Missing multiple doses of atenolol could have increased his HR which might have led to a switch to a-fib. Was he on tele by the way?

    Quote from sleepyjane
    I feel like I really screwed up bad and I need to know if I should feel this way. I worry that after the way my nurse manager spoke to me today I might be getting fired. Thats not the only thing that happened this week where I've screwed up. I had a patient that was getting discharged and the patient left before the MD saw her and there was no order written. MD came down 2 hours after the patient was on the board to leave. I finished my teaching with her, case manager went in, patient left. I did not tell her she could go, nor did I know she was leaving, but I was blamed because there was no order written. I definately feel like I am going to lose my job. 2 big mistakes in 4 days. Not off to a good start.

    Thanks for listening. I know as a new nurse I am still learning a lot. But I don't want my lack of knowledge to harm someone and I am worried that it already has.
    Is the reaction from the Nurse Manager usual for her? If so I'd look for another job - not because you might be fired, but because no one should work in a situation like that. WE will ALL make mistakes - whether first year or 20th year. Badgering, belittling, humiliating does nothing but make us second guess ourselves and lead to even worse outcomes.

    As for the second patient - forget about it. Not your fault. Patient technically left AMA.

    Hope this helps,

    Pat

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