Need Advice

Nurses General Nursing

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I am sure this is the same story many new grads have, but I need to vent! I am looking for honesty.

I have been on my own for about one month now- working on a medsurg unit. Patient admit for back pain, hx of kidney stones. Also on PCA of dilaudid. I got report from another new nurse who said she had been in pain all day, and was using the PCA very frequently. She also told me the doctor saw the pt and stated he seemed pretty "drugged" but not change anything or give any orders. Throughout the night I focused on managing pain, giving ordered antibiotics and making sure her output was adequate- she was on 200mL/hr fluids. Output was on the low end, but still adequate. During the night she had a low O2 sat, so I put her on 2L NC and that issue seemed resolved, later I took off the NC and she did not have another episode of desat). She also had some other issues:

- Low BP but not shockingly low (it was low when I came on, she was younger, surfer, very healthy + PCA pain meds, so I thought this was expected)

- Higher end of normal HR (still WNL, and in pain, so I thought this was alright as well)

- In early morning c/o "choking feeling"(I encouraged cough and take some deep breaths, which she did, she coughed up a lot of phlegm, then stated she felt completely better... I offered to suction, and she refused, I assessed lung sounds, which were clear, and I assessed for fluid retention, which I saw none)

- c/o headache, I explained a lot of our patients get headaches with dilaudid, offered tylenol, she declined.

- Around 0400, she had a temp around 100, I used light bedding, offered ice chips and a cool washcloth (my unit usually treats temp higher than 100.3)

When I gave report the oncoming nurse told me pt was becoming septic and it was my fault. By that time, labs had come in and WBC were high. During report, the new nurses aide reported a patient temp of over 101. I cannot stop thinking about if this is my fault- yes now, all signs put to sepsis, but throughout my shift, I really did not think of them as that- what I saw was each separate fairly common complications that happen FREQUENTLY on my unit especially with pain management (low BP, WNL but high HR, headache, periods of desat at night, etc).

I am a new nurse, and I feel like a lot of times, the puzzle pieces just do not all fit together for me. Many older nurses tell me that one day, I will see "the whole puzzle". Looking back, I feel SO stupid and like a failure. I literally cannot stop thinking about this, and I usually am fairly good at not bringing work home. Can an experienced or new nurse offer some advice here- I just want to know if I was a horrible nurse or if this is a new nurse mistake that can be fixed?!?!

HELP!

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Specializes in adult ICU.

YOU ARE NOT STUPID.

From the scenario you described, I would not pin this as an obviously septic patient. Subtle, early signs, perhaps, but nothing way out of line or over the edge -- certainly not septic shock at the point you are describing.

From what you described, I might say the patient "looks bad" and would monitor more closely -- you will develop a "gut feeling" about these kinds of scenarios over time when you have seen them more than once. As a noob, I think what you did was pretty appropriate. None of the interventions that you did were wrong or out of line.

Patients getting septic is not "your fault". People get sick and that is why they are in the hospital. Do not blame this on yourself. There will be a point at which the patient will have enough symptoms to warrant further eval and treatment, and I think your patient hit it at shift change with the temp and the white count. Borderline low UO, a transient de-sat, etc. can't always be pinned to sepsis, and sometimes can't be pinned to anything. Don't let the oncoming nurse make you feel crummy about it next time -- be kinder to yourself and give yourself a chance to learn.

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Specializes in Critical Care/Coronary Care Unit,.

First of all, you are not stupid. Consider this a learning experience. I'm sure you'll recognize all the signs in the future...that's how most of us learn...from experience. It definitely takes time to put the whole clinical picture together...as a new grad...you just won't have this ability. It comes with time. You start to develop a sixth sense concerning your patients after a while...where something just doesn't feel right and you need to call the MD. In my nursing practice, I learned that we don't do anything to mask fevers unless specifically ordered...including giving Tylenol, ice packs, etc...b/c these can all mask s/s of infections like sepsis. Depends on your facility policy, but a temp greater than 101...I'd definitely call the MD. Low grade temps...check your labs, ask your charge nurse, follow your gut, call the MD...they get paid a lot more than we do..so don't be afraid to get chewed out...better to get chewed out for sticking your neck out than for overlooking something that hurts your patient. Learn from this experience and when in doubt, ask. The critical thinking skills get better with time. Good luck honey.

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Specializes in Pediatrics, ER.

Rome wasn't built in a day and you are not expected to know everything in the short time you've been on your own. Looking back there are different things that you coulda/woulda/shoulda, but you'll drive yourself crazy if you do that with every patient. The best advice I can give you is to use your resources. If you're not sure about something run it by your coworkers. You'll never be faulted for overassessing.

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Specializes in ICU, PICU, School Nursing, Case Mgt.

I have to agree with Grandmawrinkle...I have many years of critical care experience and I find very little to fault you. YOu certainly assessed and assessed again, you found problems, potiential problems and solutions to them. I would not say this patient sounded septic from what you described. I would be interested to know if in fact she was.

THat being said, I also agree that after awhile, you do tend to get that "gut feeling" that the pt isn't quite right. It sounds like you did all of the correct things, the nurse that berated you should be slapped..she/he was not there and I doubt from what you described, they would have done anything differently.

You sound like you have the makings of a Great nurse.

S

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Thank you so much for your replies, it is REALLY helpful to have honest opinions from everyone. I really appreciate the help!!! Thank you!!

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Specializes in ER, education, mgmt.

I find it ridiculous that a fellow nurse would say it was "your fault" because a pt became septic. Complications happen. While there are things we can do to prevent sepsis I find nothing in your post to indicate that you caused the sepsis. Sounds like you acted within the standard of care as any reasonably prudent nurse would. Best wishes and you will be fine (hopefully your patient will too!).

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

MarBug7,

Let me say that the patient "becoming septic" is not your fault! Done and done. From your post, the nursing actions you took were appropriate, IMO. Someone who has renal calculi can present with numerous problems. If the woman was in pain the majority of the day, she probably did not want to move d/t pain. Was she lying on her back for a prolonged period of time? If so, pulmonary issues can come into play; low sats, felt like she was choking...finally coughed up phlegm...02 sat improved, no further need for 02. Elevated temp...contributes to high side of normal pulse. Low urine output and hypotension despite IVF @ 200cc/hour? That would have been cause for a call to MD, IMO. Renal calculi can certainly be a cause of sepsis, but again, your rationale for your nursing actions was definitely appropriate.

The picture of sepsis is not always black and white. It takes time to put the whole picture together (like doing a jigsaw puzzle); you can't expect this to happen overnight. I have been a nurse for 31 years, and sometimes I will miss one subtle clue that may have been obvious, but I just didn't see it. Yes, I will :banghead:, but I don't let myself get stuck, so to speak. When I was a new grad I would often come home from work and drive myself crazy second guessing myself.

In the future, if you cannot seem to put the pieces of the puzzle together, but recognize something isn't right, don't be afraid to ask. The only "dumb" questions are the ones that are never asked (does this make sense)?

Keep on keepin' on. You are on the right track. To the nurse who said "it was your fault," well, there is just no excuse for stupid....

Scoochy ;)

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Fluids were at 200, antibiotics were administered. Temp didn't go really high until you were giving report. In my experience, not much would have been done differently, even if you had notifed the MD. (MD's I work with don't usually do cultures until temp hits at least 101.)

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Specializes in Trauma Surgery, Nursing Management.

Could a lot of the symptoms that you witnessed be directly caused from the Dilaudid? Tachycardia, low BP, headache and decreased sats are ALL side effects of dilaudid. And if she was lying supine for a couple of days, she is gonna have some junk in her lungs. That will cause a low grade temp along with c/o choking. Sepsis? I would not have gone to sepsis FIRST. Remember the old analogy of looking for horses and not zebras?

You did fine. The relieving nurse needs to step off.

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