New nurse can use some advice

[sleepdeprived1]

So I am a new nurse and got my first nursing job recently.just finished my second week off of orientation im working 3rd shift and im the only nurse on my specific unit at night with a cna or two. I work in mental health so if someone needs medical attention usually have to be sent out to ER because we dont have the equipment,ivs..etc to monitor and treat at this facility..although during my orientation NOTHING exciting happened . WELL on my last shift a patient who has HTN,decreased kidney perfusion,diabetic and substance abuse issues , had a detoriation from previous day (confusion,lethargy,unsteady gait and weakness)and was placed on fall precautions and closer monitoring. Of course on my shift he falls (witnessed by myself and cna) and im freaking out like what do i do..called supervisor got vitals, pt. very hypotensive and blood sugar 418 patient helped back to bed (did not hit head no injury)..but not sure what to do? i feel like i could critically think BETTER during clinicals and in nursing school than now i feel soo dumb and im REALLY REALLY hard on myself..and terrified that i am ON MY OWN..i tried to page dr. for over hour with no response then i called other on call and he calls back of course i feel i am stumbling over the information to tell him about pt. he was prob. not familiar with and looking back now i can think of what and how i would report info to doc better but under pressure i do terrrible..cuz i am nervous too..doctor orders labs,monitoring more freq. vitals.....dr. calls back two min. later and asks me more questions about pt.'s med. hx. and i tell doc. and then doc. asks me if pt needs to be sent out..i wanted to say 'I DONT KNOW I BARELY KNOW WHAT IM DOING..but i tell him im not sure and that it wouldnt hurt..then says ok we can send him out..supervisor then seems upset? and is like what is he being sent out for?? and i wanna say 'I DONT KNOW" because im doubting myself for everything at this moment but pt. was declining from previous day in level of consciousneess confusion blood sugars elevated and weakness and had a fall and blood pressure fluctuating ...well finally pt. sent via ambulance to hospital..and one question i have is i never gave insulin..i know he needed it but it was scheduled (and pt. received insulin on other shifts before i came in)and doc. was aware of BS level but never said to give..(thats another thing im nervous about administering insulin i havent done since nursing school and heard horror stories of nurses killing pts. with too much insulin..and on my noc shift i havent had to give but know i need to review and prob. have a nothr RN just check me draw up once to make sure..and i know i need to STOP being soo nervous and unsure of myself if i will ever become a good nurse..but im having a hard time. I could really use some advice feedback anything to get through being a new nurse and how to build up my confidence so I CAN CRITICALLY THINK without having to be reminded on what to do..i just cant seem to stop thinking about this incident and what i could have done differently also doc. ordered neuro check but supervisor said ok to let hospital do it..i prob. should have done one..aagggh i hate being a new nurse:bluecry1: someone tell me it will get better

[NurseCard, ADN]

It will get better. Stop being so hard on yourself.

Some advice:

Calling a Doctor: I have worked at a couple of facilities who used

the SBAR model of reporting to a doctor, OR when giving report at

end of shift. You can use this yourself when you call a doctor:

SITUATION: "Dr. Jones, this is Jenny Nurse, calling from unit 3 at

City Mental Health Center. I'm calling you about a patient of yours (or

a patient of Dr. Smith's), Miss Jane Doe."

BACKGROUND: "She is a 49 year old lady admitted to our unit on June 1st

for ETOH Detox. She has a history of Diabetes Type 2, Hypertension, and

kidney disease, as well as a long history of alcohol abuse."

ASSESSMENT: "She has just fallen. I've assessed her; she does not appear

to be injured; no bruising... range of motion in all limbs is OK. No pain.

However, her blood sugar was 418, her blood pressure is 200/108, she is

confused, lethargic... confusion, lethargy, blood pressure, all seem to be

getting worse over the past 24 hours."

RECOMMENDATION: "Would you like me to administer insulin for the blood

sugar, and would you like to order a PRN for the her elevated blood pressure,

and have us continue to monitor her? Or do you feel like she needs to

be sent out to the hospital for evaluation?"

------------------

The recommendation part is a biggie; doctors love that. What does the

patient need that isn't currently being done, or isn't currently ordered?

Whatever that thing is, you can suggest it to the doctor. I've found that

more often than not, doctors welcome your suggestion.

GIVING INSULIN: You should have gone ahead and given the insulin if

the patient had sliding scale ordered. However, I do understand your

fear of having the patient bottom out. At night, you can certainly give

a small snack after administering the insulin. A complex carb and a

protein is a great idea. Peanut butter on wheat bread is a good idea.

Hope that helps. =) Cathy

[sleepdeprived1]

Thanks for the input and advice! Im going to use this SBAR from now on!

[GitanoRN, BSN, MSN, RN]

i agree 100% with the previous post and let me reenforce that it will get better with time, we all been there one time or another at the beginning of our career. therefore, by playing the scenario over in your brain on the events it allows you to step back with a clear mind, and re-evaluate what you could have done better and apply it in the future. having said that, we all underestimate ourselves at the beginning, however, i promise you too will have the answers and will be able to address any future situation with more conviction. wishing you the very best, as i send you a hug :hug: from across the miles...aloha~

[PeepnBiscuitsRN]

In school you're not put on the spot with a real patient who can real-die, in nursing school you have pretend patients who pretend die until the next lab. It's hard when a doc calls you back and then asks you what should be done- I've had it happen and have wanted to say "hey, am I the one with the white coat and $500.00 stethoscope?"

Anyhow, if you have a medical administration record or even a patient care plan, there ought to be an order for sliding scale insulin based on blood sugar. I'm not a fan of insulin administration either, but thankfully having worked on night shift it hasn't been an issue for me unless the evening nurse tells me "he's been running super low, and has had a couple of amps of D50 today and I went ahead and gave him his bedtime Lantus...and his blood sugar at bedtime was 72. Thankfully this hasn't happened for real. If you're worried about bottoming out, just do a spot check or two...every 2-4 hours or something like that.

I wonder why he was so hypotensive. You were totally in the right for calling the doc, something must be going on: change in LOC, blood sugar really high, blood pressure really low...I learned that as you go along you'll start to get that little nurse on your shoulder who tells you, despite the previous shift saying the patient has been fine, "this patient is not fine..." and you listen to that little voice and oftentimes you're right. Or to put it another way: is it going to harm the patient to stick their finger in the middle of the night to check their sugars? No. Is it going to harm the doctor to give them a call to run the situation by them? NO! That's why they get paid the big bucks! Now, is it going to harm the patient to NOT check them and have their FSG be 29 or 799? YES. Is it going to harm them if you just brush their change in LOC, hypotensive state and weakness off and they're septic? YES. I'd rather pi$$ off a doc than kill a patient.

[sleepdeprived1]

All really great advice soo far thanks!!! Cant wait until i get more experience but in the meantime thanks for the words of encouragement and advice!