What I don't know can hurt you!!!! (long)

  1. Hi All!

    Ya'll know I don't post here often, but I really need some support right now!

    The other day I had a patient that was c/o pain in his legs. He had had lortab 5 about 3 hours prior and it would be another hour before he could have it again, so I gave him tylenol 325 x 2. Then an hour later I gave him the lortab when he asked for it. When I was reporting off to the oncoming nurse (who graduated with me and is miles ahead of me) looked at me like I was stupid and said "what about the 4000 mg limit?" I had no idea what she was talking about!!! I feel so stupid!!! This is basic nursing stuff and I don't know it. I've been beating myself up over it for days now. Don't get me wrong, I'll not forget it now, but I just keep thinking about how much damage I could do with what I don't know.

    As if this isn't bad enough, I got an admit the other night who's ABGs were showing metabolic acidosis and I couldn't figure it out. The nurse who I reported off to gave me attitude...let me sum up...
    I had one patient and was waiting for the admit from ER. At 2030, I gave my patient his 2100 meds so I could be ahead of the game when the admit came. I missed his zantac. I gave him his lipator and flushed his SL with NS and Hep-Lock solution. My admit came in and I got her settled in and assessed. She was pretty out of it. She would wake up long enough to answer a question or two and then fall back asleep (snoring). She was real thick tounged and wasn't oriented to time or place. She started wriggling around on the bed and moaning, so I went back in (I was at the desk tring to get the chart together b/c the doc was there) and she told me she had a bladder infection and it hurt "down there". So I asked the doc if he wanted me to get a UA. He said yes and I asked if he wanted me to cath her. He said "what ever it takes". Well, I got her OOB to the bedside commode at her request, got the sample in a nurse's hat, and sent it to lab. The nurse that was taking my place came on at 2300 and started going thru pt A's chart. She immediately found that I missed the zantac and asked - demanded - what I was going to do about it. I told her I would take care of it before I left, but I was trying to get the chart together and the orders done for pt B so she wouldn't have to do it. (Nothing makes the nurses on my unit angrier than leaving unfinished orders for them.) Then pt A calls and says, of all things, his stomach is upset. So she says, "I'll get you something for that" and tells me she is going to get the zantac for him. I say "thank you". Then she comes out of the med room and says "Are you sure you didn't give the zantac because it's not in his drawer." I say "No. I only gave the lipator." She says "Are you sure, it's not there. Are you sure you didn't give it?" I say no, "I gave two lipator and flushed the hep-lock" She says "but it's PO zantac" I say, "that's what I'm saying the only PO med I gave is the lipator and I flushed the hep-lock" She says, "Calm down. I just need to be sure" (so the 1st 2 times I told her wasn't good enough?) Anyway, by this time it's 2400 and RT comes to draw the ABG on pt B, comes back, gives the results to the other nurse and says "She's compensating somewhere, it obviously metabolic". Now the other nurse go in to look at the pt, comes out, goes to the supply room, and comes out with a foley kit. I ask why she is going to cath the pt and get ignored. I tell her that I got her up to the bedside commode and I don't think she needs cathed. She says "Well do you know how much she put out when you got her up?" I say yes, and tell her the amount. At which point she goes into the room to cath the pt. Then she tells me the pt is getting septic and needs to be cathed because we need to keep and hour by hour update on her output. I remind her that we don't have an order to cath - the doc only said to do it if it was necessary. (This gets ignored) I then tell her I'm going to ER to get pt B's pm meds and that I'll get the antac for pt A. (this gets ignored too) I go to ER, get the meds, come back, give the PM meds to pt B, the zantac to pt A, wrap up a couple more things, and left for the night. Again feeling like the stupidist nurse in the world. How do I know when a pt is "going septic" and is in metabolic acidosis and...and.....and......

    I know this post is long, and I apologize for it. I don't know what I'm looking for - support, acknowledgement, sympathy, empathy, all of the above....

    Thanks in advance for reading this.

    A.W.
    •  
  2. 14 Comments

  3. by   DutchgirlRN
    [quote=ArmyWife,RN]Hi All!

    Don't beat yourself up, it sounds like your co-worker did a pretty good job of it already.

    My only advice, being that I don't understand ABG's either, is that anytime you have abnormal values in an ABG report, find RT and ask them to intrepret them for you. Then you will have info enough to make a decision and call the doctor if needed.

    Giving more than 4000mg of Tylenol in 24 hours is not the correct thing to do but it's not going to hurt the patient if only done once. Give yourself a break. You learned a lesson. That's important.
    Last edit by DutchgirlRN on Nov 4, '05
  4. by   GrnHonu99
    no one is perfect and I bet you wont make those mistakes again!
    I suggest getting a book on acid base balance. I use Prentice Hall's. Its orange and white..its really great.
  5. by   SouthernLPN2RN
    Don't be so hard on yourself, just take this shift in stride and learn from it. You will find that some nurses are never happy and nothing you can do will change that. Some nurses are also seemingly out to make other nurses look bad. In regards to the foley, ask the nurse more about it in a non-confrontational way. A cath to collect a specimen is going to be an in and out, not indwelling. Some docs will allow nurses to do stuff like that and they just sign the order when they come in. Where I worked, indwelling's weren't placed without a specific order, and the bladder should be scanned first. If this pt wasn't having problems voiding, the cath shouldn't have been there, IMHO. It just adds another risk for increasing infection.
  6. by   jenrninmi
    Wow! You know, like the others said, don't beat yourself up about these. Was it the 4000 mg of acetaminaphin you didn't know, or was it that you didn't know Lortab had acetaminaphin in it? Well, now you know both! :0) It's not going to kill the patient if it happened once. About the ABGs - Where I work, a foley is never put in place without an order. She should have called the physician about that. And definately should have bladder scanned the patient first. It doesn't sound like the nurses are treating you well and seem to forget what it's like to be a newer niurse.

    Have a great day!
  7. by   txspadequeenRN
    Everyone has bad days , dont beat yourself up. Learn from the mistakes and move on. Sounds like you had alot going on. The one thing in nursing school that stumped me was metabolic acidosis and I cant say I even now understand it completly. As for the Tylenol , you gave 325x2 equalling 650mg then Lortab (probably 5/500) that is 1150mg. That is way off the limit. You still have to be carefull of those that have liver impairment in that there dose limit may be lower. You sound like a very caring nurse. Just keep on keepin on...
  8. by   JentheRN05
    Everything comes with time and EXPERIENCE if you haven't had a septic patient you may miss the signs. Here's my question, were they running a fever? Septic patients generally run a fever. She could easily go septic from the UTI, but unless there's orders to cath, you don't cath (especially against patients wishes!) If the patient was indeed confused that would follow along with the metabolic acidosis.
    In either case, DO NOT beat yourself up over this. All good things come in time. When you go into work the next day, since the hecticness of this particular night is over, ask the nurse (the one who suggested the patient was going septic) how she came to this conclusion. Tell her your new at this and would really like to be able to recognize the signs when/if you get another patient like that.
    I'm sorry about your night it truly will get easier with time.
  9. by   UM Review RN
    Quote from ArmyWife,RN
    Hi All!

    Ya'll know I don't post here often, but I really need some support right now!

    The other day I had a patient that was c/o pain in his legs. He had had lortab 5 about 3 hours prior and it would be another hour before he could have it again, so I gave him tylenol 325 x 2. Then an hour later I gave him the lortab when he asked for it. When I was reporting off to the oncoming nurse (who graduated with me and is miles ahead of me) looked at me like I was stupid and said "what about the 4000 mg limit?" I had no idea what she was talking about!!! I feel so stupid!!! This is basic nursing stuff and I don't know it. I've been beating myself up over it for days now. Don't get me wrong, I'll not forget it now, but I just keep thinking about how much damage I could do with what I don't know.

    As if this isn't bad enough, I got an admit the other night who's ABGs were showing metabolic acidosis and I couldn't figure it out. The nurse who I reported off to gave me attitude...let me sum up...
    I had one patient and was waiting for the admit from ER. At 2030, I gave my patient his 2100 meds so I could be ahead of the game when the admit came. I missed his zantac. I gave him his lipator and flushed his SL with NS and Hep-Lock solution. My admit came in and I got her settled in and assessed. She was pretty out of it. She would wake up long enough to answer a question or two and then fall back asleep (snoring). She was real thick tounged and wasn't oriented to time or place. She started wriggling around on the bed and moaning, so I went back in (I was at the desk tring to get the chart together b/c the doc was there) and she told me she had a bladder infection and it hurt "down there". So I asked the doc if he wanted me to get a UA. He said yes and I asked if he wanted me to cath her. He said "what ever it takes". Well, I got her OOB to the bedside commode at her request, got the sample in a nurse's hat, and sent it to lab. The nurse that was taking my place came on at 2300 and started going thru pt A's chart. She immediately found that I missed the zantac and asked - demanded - what I was going to do about it. I told her I would take care of it before I left, but I was trying to get the chart together and the orders done for pt B so she wouldn't have to do it. (Nothing makes the nurses on my unit angrier than leaving unfinished orders for them.) Then pt A calls and says, of all things, his stomach is upset. So she says, "I'll get you something for that" and tells me she is going to get the zantac for him. I say "thank you". Then she comes out of the med room and says "Are you sure you didn't give the zantac because it's not in his drawer." I say "No. I only gave the lipator." She says "Are you sure, it's not there. Are you sure you didn't give it?" I say no, "I gave two lipator and flushed the hep-lock" She says "but it's PO zantac" I say, "that's what I'm saying the only PO med I gave is the lipator and I flushed the hep-lock" She says, "Calm down. I just need to be sure" (so the 1st 2 times I told her wasn't good enough?) Anyway, by this time it's 2400 and RT comes to draw the ABG on pt B, comes back, gives the results to the other nurse and says "She's compensating somewhere, it obviously metabolic". Now the other nurse go in to look at the pt, comes out, goes to the supply room, and comes out with a foley kit. I ask why she is going to cath the pt and get ignored. I tell her that I got her up to the bedside commode and I don't think she needs cathed. She says "Well do you know how much she put out when you got her up?" I say yes, and tell her the amount. At which point she goes into the room to cath the pt. Then she tells me the pt is getting septic and needs to be cathed because we need to keep and hour by hour update on her output. I remind her that we don't have an order to cath - the doc only said to do it if it was necessary. (This gets ignored) I then tell her I'm going to ER to get pt B's pm meds and that I'll get the antac for pt A. (this gets ignored too) I go to ER, get the meds, come back, give the PM meds to pt B, the zantac to pt A, wrap up a couple more things, and left for the night. Again feeling like the stupidist nurse in the world. How do I know when a pt is "going septic" and is in metabolic acidosis and...and.....and......

    I know this post is long, and I apologize for it. I don't know what I'm looking for - support, acknowledgement, sympathy, empathy, all of the above....

    Thanks in advance for reading this.

    A.W.
    *sigh*

    There's a bully on every unit, isn't there. Some nurses make learning your job a joy and others can really make learning a nightmare.

    You need to set firm boundaries with this nurse and do it fast, and do it now, or she will continue to treat you badly whenever you have contact with her.

    So before this scenario repeats itself, you need to have a real talk with her about treating you with respect.

    It's easy to come in and be critical of another's work, but try to remember that only really insecure people behave like that.

    Knowing why is not an excuse, however. Insist that she treat you with respect, or take it to your manager. Don't feel badly about your work because no matter what kind of errors you made, NO ONE HAS THE RIGHT TO TREAT YOU BADLY. NO ONE. For ANY reason.

    This is a good website about bullying behaviors and how to nip them in the bud before your work or your health starts to suffer from being around these types of people. Arm yourself with knowledge and learn how to defend yourself now because you are, like me, a non-confrontational type who is often the Perfect Target of the bully at work.

    http://www.bullyinginstitute.org/def.html
    Last edit by UM Review RN on Nov 6, '05
  10. by   UM Review RN
    I say all that above because if I knew you were a new grad and I took report and found those errors I would either tell you about it gently, asking you to view it as a learning experience, or I would've seen that you were completely overwhelmed and I would've taken report and just taken over patient care and done my thing without hassling you further.

    Which is how that whole scenario should have gone down. Not as a situation in which I make myself look like the "better" nurse. We all have different learning curves, we all have gaps in our education and knowledge base.

    Collegiality means that we TEACH one another, not harass one another.

    See the difference now?

    I know that you are interested in improving your work, but truly, that is not what the scene you describe is really all about, is it.

    Take care, and know that we do care, we are happy to help you, and you can vent here anytime.

    ~Angie
    Last edit by UM Review RN on Nov 6, '05
  11. by   RainDreamer
    I'm so sorry you're having a rough time. I can't really offer you much advice because I'm going through the same things you are. Some days I feel like such an idiot. It doesn't help when your co-workers aren't supportive. It's normal to feel like this though, we'll get through it. ((((HUGS)))) for you.
  12. by   perfectbluebuildings
    No great advice here... just another new nurse who is going through the same thing... (hey there ArmyWife and Raindreamer! )

    And to Angie... THANK YOU for being that kind of nurse and not making us feel more stupid and incompetent than we already do! You and nurses like you make such, such, SUCH a big difference. THANK YOU from a still very uncertain new nurse.
  13. by   hrtprncss
    Hi I just wanna give u a resource on ABG if you want it... Go to this link http://realnurseed.com/abg.htm and go to the section of "The Land Of ABG's". By Vonfrolio. I've posted it before somewhere and it has helped a few. It's quite simplistic. So hopefully it helps!
  14. by   KatieBell
    I've seen several new grads get into this situation. Part of this is someone being a ninny on the floor where you are, the other part- is maybe not having enough time to process things.

    I was just talking to the educator at my old job where they have hired several new grads at once. Many of them are having difficulty actually learning from "mistakes" because they are taking care of so many patients in and out of the door.
    The advice I can give is to try to take time to look stuff up. You might not know about a 4,000 mg limit, but since you are giving lortab, you should know what is in it, not just that it is a pain med.

    Secondly- look into classes offerred by the Cont. Ed department. Many give great info, allowing you to be more confident in patient care. In addition, you get to meet people outside of your department, who can become part of your support.

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