Staying safe vs being new with too much to do

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    Well I just typed a LONG post and my dog deleted the entire thing so let me just make this short and sweet lol.....
    I'm new to a busy med-surg floor, I was lucky enough to get hired immediately upon graduating so I've been here 3 months and on my own for 3 weeks. I feel that I'm a fast learner and I do manage to finish all my work/charting on time. Also my patients absolutely love me so that's probably my strongest point so far.

    My concern is this...I feel that nursing school prepared me to be an awesome CNA! Just not so much an RN. There's so so much to learn and I feel that I've forgotten alot from school, or maybe much of the knowledge I feel I'm lacking I was never really taught in school anyways, I can't remember. I want to be able to finish everything in a timely manner but also feel that I'm doing the best I can do to be safe and effective. I know some of this will come with time but let me give an example...

    The PCAs on my floor inform us if a blood pressure is a little too high or low, which is great. But when it's a busy day and they tell me a pt. bp is 178/90, at what point do I say "oh wow that's entirely too high I need to call the dr"...I mean I know obviously if they had any prn bp meds i would give those but what if they don't have any prns ordered....If their bp is normally low I would be more concerned but what if it usually runs 140/80's.....I don't want to dismiss anything serious but I've seen so many nurses handle similar situations differently. Some will dismiss it and say we will keep a check on it, it's probably up because they've been moving around (for example) while others freak out and call the dr immediately.

    Or if the bp is low, at what point do you call the MD?
    I mean don't get me wrong if I need to, if something's going on I don't know how to handle I go to other nurses or the charge nurse all the time....this may sound bad but I don't care if I get on their nerves because I want to be safe. I'm not going to just wing it and hope I made the right decision. But I want to be more autonomous.

    Besides BP, what about post-op with a temp? I had one of those the other day and I immediately thought "tylenol" but then I wondered if that would just mask the temp and we needed to know what it's really running...then the charge nurse told me not to give tylenol to get her up and walking. I had no idea or either forgot that this would help? I just feel lost on some things, I feel like I should better know how to care for my pts in some situations. Will this come with time? Has anyone else felt this way?
    Sorry I guess this did end up being a long post after all
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    Also didn't mean to make this sound like I'm entirely concerned with just BP and temps, I really mean any and everything! lol resp distress, CP, HA that won't go away....what are some common things you may see on a med-surg floor and how do you initially handle them?
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    I don't have much advice but First off recheck the vital yourself. With BP grab a manual BP, can't tell you how much I hate those automatic ones.
    Tooimpatient likes this.
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    I just wanted to comment and say that I'm in an identical situation! I recently graduated and was one of few to be offered a job before graduation on a med/surg floor. I worked as an aide during school, and I know that school helped with that. However- on clinical, we were only ever given 1 patient. So, for me to start out on a med/surg floor where they have 7-9 patients per nurse is extremely overwhelming for me. I'm beginning week 3 there (my orientation is 6 weeks long) and I feel like an idiot almost everyday. I never know when to call the doctors, let alone WHICH doctor to call. It's very frustrating. I think my patients like me, but I always feel bad because I don't get to spend very much time with them short of passing meds and assessing them. I haven't felt like a very effective nurse yet and I've needed a lot of guidance, and I'm really hoping that will change sooner than later. I'm wishing you luck!!!
    SunnyRose and Tooimpatient like this.
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    Quote from cll72089
    I just wanted to comment and say that I'm in an identical situation! I recently graduated and was one of few to be offered a job before graduation on a med/surg floor. I worked as an aide during school, and I know that school helped with that. However- on clinical, we were only ever given 1 patient. So, for me to start out on a med/surg floor where they have 7-9 patients per nurse is extremely overwhelming for me. I'm beginning week 3 there (my orientation is 6 weeks long) and I feel like an idiot almost everyday. I never know when to call the doctors, let alone WHICH doctor to call. It's very frustrating. I think my patients like me, but I always feel bad because I don't get to spend very much time with them short of passing meds and assessing them. I haven't felt like a very effective nurse yet and I've needed a lot of guidance, and I'm really hoping that will change sooner than later. I'm wishing you luck!!!
    Well I hate you are having a hard time too but it's good to see I'm not alone! Lol we normally have 5-6 pts, I can't imagine 7-9....that's awful :/ and I know exactly what you mean I never knew it would be so complicated like the smallest things such as WHICH dr to call, do you page them or call their office, is there someone on call that you contact rather than the MD, etc. and consults.....that's something totally new to me. I had a 6 week orientation also, I guess it seemed long enough because really no amount of time would ever make me feel completely comfortable. Just had to be kinda thrown out there.
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    I would start with analyzing how far from the patient's baseline are the "changes" you are seeing. If a BP is in the 170's and they are moving, I typically wait a few minutes and recheck. Often times the BP will settle after some rest. Also check on symptoms. If you have a patient that has a lower than usual BP but are asymptomatic I am less frantic than if they are pale, dizzy, or showing other symptoms. For low BP, i check it manually. Usually our floor is concerned if SBP<90 unless other parameters are written by the docs. Check meds that were given recently... Could any of those caused the drop? If the BP is still low after checking, I would call the doc. If the BP is consistently in the 170's but never meets the prn hydralazine order or other meds parameters, I would call the doctor to see if they would like to add or increase their already scheduled BP meds. Also address pain since that can elevate BP. If its a one time occurrence and decreases I wouldn't call. Post-op low grade fever is common. Get your patient moving, get them deep breathing and coughing and esp use the incentive spirometer! Ive had a patient with a mild temp, made them work with the incentive spirometer for awhile, then bam the temp was gone! Now if its consistently trending a temp, with or without tylenol given, you should call the doc... They may want blood cultures or other interventions! Hope this helps. Always go with your gut and ask your charge nurse if you have questions. Always double check vitals prior to calling docs and see if simple interventions fix the issue prior to calling. Hope this helps! Goodluck!
    BSNbeDONE and Tooimpatient like this.
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    What are your organizational policies & procedures related to these issues? That should be your first line of defense. Also make sure you review physician progress notes & all PRN orders to see if VS parameters have already been addressed. If not, DO NOT attempt to make independent judgments about treatment of persistent VS changes - ALWAYS call the physician. "Failure to communicate" is one of the most common element in most inpatient lawsuits involving nursing practice issues - the second is violation of scope of practice (practicing medicine). Whenever you are confronted with a new finding or change in patient status - always call the physician & document that you have done so.

    Keep on listening and acting on those gut feelings - that something is wrong. Don't be afraid to act - especially if your patient's MEWS score is actionable. Don't be afraid to trigger the RR team if necessary. Your most important role is Patient Advocate and this may sometimes take courage.
    Altra likes this.
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    Do your typical admission orders include parameters for things like vital signs, urine output, etc.?

    What you are describing does sound typical for your limited level of experience. In your first 6 months as a nurse you'll learn more than you did in all of nursing school. It really does take a solid year to begin to feel competent. Keep on asking questions - especially the *why* questions. That will keep you & your patients much safer than simply carrying out the same interventions you saw another nurse carry out.
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    I usually call on a DPB>100 right away, or a SBP>180 if it's a new occurrence. The DBP >100 is a little more alarming to me. It depends on my priorities though; I remember my ABCs. Always look at the trends and recheck BPs that are critically elevated. I call for SBP<90 if it's a new occurrence, especially if it's a symptomatic pt. Ask for orders for PRN meds for High BPs. Don't be afraid to call docs or to get behind in charting. Always take care of the patient first and the paperwork after. If you work days utilize the time when docs round to update them on your patients. Assess the patient and not just the monitor also. Electronic BP machines tend to be not as accurate as a manual BP. And follow your instincts too; if your gut is telling you something; listen to it.
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    It's very scary being a brand new nurse in a busy acute care unit. There is so much we don't know, and we don't even know what it is we should know that we don't. I guess knowing hospital policies and procedures, and asking lots of questions must suffice. Checking and double-checking. Hard to do all this, be safe and efficient, and finish it all on time, indeed.
    Last edit by Flatlander on Sep 12, '13


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