Rookie RN - Serious Questions

NewEastCoastRN · Feb 27, 2005

Hi, I have been a nurse on a unit similar to yours for about 1 1/2 years. Here is my advice, question by question:

How do you tell if a patient is going bad?

As you gain more experience, it is true that you will get the "gut feeling." But more importantly, since you are the one with the patient hours on end, you notice trends, either in how they look or how they act. Also, always check vital signs whenever you feel that something "isn't right." And obviously, ask the patient if they are feeling any different.

When is a blood pressure too high?

Depends. Look at their baseline. We usually act when it is around 160 systolic.

When is a blood pressure too low? Is there a panic level?

Depends again on their baseline. If they run consistently low, it becomes a problem if they are symptomatic. Also, if a patient is very high and drops to what we would consider to be a "normal" BP, this could also be too low for the patient.

What if there is a huge difference in the ortho B/P's? Do I call or just chart?

Is there any interventions I can do without a doctors order?

Call if they are orthostatic and it is a new finding. Keep them in bed with the head somewhat low.

I know you call a code if someone is not breathing or no heartbeat. That much I did get out of school and BLS. But how do I know it is coming?

You really can't ever know FOR SURE. I think that the instructor is just lucky. You can always look for warning signs (mental status changes, vital sign changes, etc) but you can never really know all the time.

I hope this info helps!

UM Review RN, ASN, RN · Feb 27, 2005

Hello - I have been an RN for about 2.5 weeks. I am currently in an orientation program for a tele/PCU floor.
I have some questions. I do not want to appear uneducated at work. But alot of things I just do not feel were covered in school or in text books. I have asked some questions, but get unclear responses.
How do you tell if a patient is going bad? I know I have gut feelings.....but when do I call the doctor? I don't want to call the doctor just because.....what are my key warning signs? I want to be able to provide the doctor with logical, objective observations that they may not have picked up on during their rounds. Do my instincts count?
When is a blood pressure too high?
When is a blood pressure too low? Is there a panic level?
What if there is a huge difference in the ortho B/P's? Do I call or just chart?
Is there any interventions I can do without a doctors order?
I know you call a code if someone is not breathing or no heartbeat. That much I did get out of school and BLS. But how do I know it is coming...... I had an instructor tell me she did not experience codes because of her excellent assessment skills. I was like *WOW*. She is super nurse. So too shall I strive........
Can anybody help me and my future patients?
Many thanks in advance.

Hi Flashy, I'll attempt to answer some of your questions, but please remember that my answers are based on being a night shift nurse. Our protocols will be different from other shifts.

Vague answers also bothered me when I started working Tele. I quickly learned that whether the doc was called was dependent on other things. That's why your answers seem vague. Tele nursing is a lot like English grammar--there are rules, but there are also plenty of exceptioins.

Bearing that in mind, the key is to be able to recognize trends and know your protocols for different conditions. Also bear in mind that being new to tele, you might be calling the doc and telling him something he's heard oh, about a hundred times before. Read the orders, the doc's progress notes, and the patient history. Does the doc know that the patient's K is 3.4 by writing it in the progress notes? If so, he might've added some K to the IV fluids or he might just wait until tomorrow's labs to treat it. Does the patient have a trend of flipping in and out of VT? If so, maybe those 8 beats you just saw might not need to be called asap, especially if the patient is symptomless.

Know your protocols. If you have a newly diagnosed stroke patient whose temperature is 99, you give them Tylenol 650 mg either po or pr. You would not give the post-op patient Tylenol for a temp of 99, however, because an elevated temp up to 101 is actually desirable in a postop, but it's not good in a stroke patient.

In general, you can call the doc if the patient's BP is dropping fast--say the patient's normal BP is up over 100, now they're BP is low 80's and they're feeling lightheaded. You have two bad symptoms there. In that case, I would tell your charge--she might be able to help you--then put a call out to the doc and try to get the patient to lie flat till you get orders. Some of our docs like to start a bolus of NS to get more volume on board.

You also would want the doc to know of rhythm changes, especially if someone goes from Sinus to A-Fib with RVR. Even if the patient has a history, the doc might want this patient to get on a Cardizem drip.

Instincts do count, but try to be specific: "The COPD patient's color was ruddy before but now his breathing is more labored, resps are high, he's c/o SOB, and his color looks dusky. Even though is vitals are ok, and his O2 sat is ok, he has deep sternal retractions as he's breathing. He refuses to even lie down in the bed due to the SOB. I don't have a good feeling about this fella right now. I called the RT, the patient had a nebulizer treatment, but hasn't improved much. Do you want ABG's? a CXR? Lasix??"

That last one actually happened by the way. We really had no proof by the numbers that this fella was going bad--his ABGs came up fine--we just really felt like his heart couldn't take much more of the respirations at 47 a minute. We sent him to the unit on a Bipap after some IV Lasix and he was much more comfortable. When he came back in a few days, the official dx was that he'd had CHF. We must've caught it early.

I guess my point is that there's no substitute for experience. I remember being completely wowed as a new tele nurse when I came into a patient's room to assess her and she was completely unresponsive. I panicked and hit the Code button.

One of the more experienced nurses came into the room and TOOK OFF the O2. But it proved to be the right thing to do--some visitor thought the patient would do better at a higher rate of O2 and had jacked our CO2-retaining patient up to 5L, causing the patient to pass out a couple of hours after the visitor left!!

So in general, you read the chart. You read the orders, do an overview of the labs and test results, then look at the doc's progress notes. Look at the vitals and history and note any trends. THEN if your patient looks badly, you might be able to figure out why and if it's a change that warrants calling the doc. As a new nurse, I'd err on the side of calling.

I called one doc in the wee hours because I had a patient flip into A-fib with RVR at a rate of about 140 while she was asleep. She was asymptomatic. I called the doc and he was annoyed. He said something like, "She does this all the time. What are you doing, calling me about it?" Irritated and upset by his tone, I snapped back, "I am LEARNING, that's what I'm doing, and I wanted to do what's safest for the patient." Immediately his attitude changed. He had me give a bolus of Cardizem and start a drip on the patient.

I did great except for one tiny thing--I hadn't taken my unit's Tele test and wasn't officially certified to give Cardizem as a bolus!

I freaked. But my charge just handed me the test and said, "Just pass the darned thing already" so I did and became "official."

begalli · Feb 27, 2005

Hello - I have been an RN for about 2.5 weeks. I am currently in an orientation program for a tele/PCU floor.
I have some questions. I do not want to appear uneducated at work. But alot of things I just do not feel were covered in school or in text books.

These are the EXACT questions you should be asking in your orientation program. I can tell you right now that the new who doesn't ask questions is the one who is worried about.

Any half-way decent facility will know that you don't know and will be concerned of you seeming to already know all the answers. They expect you to ask questions. Coming off like you already know is not good for your practice or the safety of the patient.

If you don't understand a question, keep asking until you get an answer that is clear to you but remember that each and every patient is unique and one single answer covering everything doesn't work. That's probably why you get unclear answers when it comes to specifics like "how do you tell when a patient is going bad."

YES! Your instincts DO COUNT!! What I would do if I were you and what I did was new and still do now, is run your findings by another nurse before calling a doc. I think most nurses do this no matter how much experience they have.

Don't worry, you will not "appear uneducated." Everyone goes through this. It's going to take you a good year+ to get the sublties down. It takes time. Be patient with yourself.

One thing you might want to ask is if the docs at your facility leave parameters for things (eg: vital signs, urine output), what do you as a nurse have in your orificenal (doc orders) to address such things (eg: drugs, fluids), and if and when to call the docs want to be called and for what (the parameters).

Good Luck!

UM Review RN, ASN, RN · Feb 27, 2005

Also, I forgot to mention:

When taking orders for things like BP meds and ortho BPs, you might ask, "And would you like to have us use parameters for giving that medication?" (Or that ortho BP?)

For instance, some docs want you to have a prn Clonidine order for a patient but the number will vary widely as to when to use it. I've seen a doc write to give the prn at 140; others go all the way up to 200, so it really can get to be a mind-reading game with these docs about certain things.

Liddle Noodnik · Feb 27, 2005

It's really cool to see you guys respond like this to our "rookie RN" - I can remember having questions like that but my charge nurse had only 6 MONTHS more experience than I!

You know what? I actually transferred to the ICU after MY six months partly because I needed more experienced guidance! I couldn't get it on my floor!

One of my earliest experiences in ICU - in fact I think I was still orienting - I had a patient code on me, one minute, nice and pink, next minute blue and unresponsive! I was so baffled and guilt ridden, like, "Why hadn't I seen this coming?" Just totally blown away. I ended up going to the autopsy because I was convinced that somehow I had failed this man who, I think, was only in his 50's.

Turned out he had a pulmonary embolus - and the doc who did the autopsy was awesome, telling me there was nothing I could have done differently, or seen ahead of time - I'll tell ya, it's something I never forgot ...

UM Review RN, ASN, RN · Feb 27, 2005

Turned out he had a pulmonary embolus - and the doc who did the autopsy was awesome, telling me there was nothing I could have done differently, or seen ahead of time - I'll tell ya, it's something I never forgot ...

Oh boy, do I know what you mean! There's not a more helpless feeling in the world, is there, when a patient throws a PE!

Liddle Noodnik · Feb 27, 2005

Oh boy, do I know what you mean! There's not a more helpless feeling in the world, is there, when a patient throws a PE!

It killed me that this guy was so young, too!

UM Review RN, ASN, RN · Feb 27, 2005

It killed me that this guy was so young, too!

Mine had multiple comorbities, but still!! not a good way to go!

I read up on DVTs/PEs and found some interesting (read: frightening) facts:

http://www.preventdvt.org/aboutDVT/index.asp

According to the American Heart Association, up to 2 million Americans are affected annually by DVT
Of those who develop PE, up to 200,000 will die each year
More people die in the United States from PE than breast cancer and AIDS combined
According to the American Heart Association, DVT occurs in about 2 million Americans every year.
More people suffer from DVT annually than heart attack and stroke.
Up to 600,000 people are hospitalized in the U.S. each year for DVT.
Fatal PE may be the most common preventable cause of hospital death in the United States.
Only one-third of hospitalized patients with risk factors for blood clots received preventive treatment, according to a U.S. multi-center study.
Without preventive treatment, up to 60 percent of patients who undergo total hip replacement surgery may develop DVT.
Cancer patients undergoing surgical procedures have at least twice the risk of postoperative DVT and more than three times the risk of fatal PE than non-cancer patients undergoing similar procedures.
In the elderly, DVT is associated with a 21 percent one-year mortality rate, and PE is associated with a 39 percent one-year mortality rate.
PE is the leading cause of maternal death associated with childbirth. A woman's risk of developing VTE is six times greater when she is pregnant.

Liddle Noodnik · Feb 27, 2005

. A woman's risk of developing VTE is six times greater when she is pregnant.

VTE, is that a typo or am I missing something :)

Thanks Angie, didn't know it was so prevalent!

Gompers, BSN, RN · Feb 27, 2005

These are the EXACT questions you should be asking in your orientation program. I can tell you right now that the new who doesn't ask questions is the one who is worried about.
Any half-way decent facility will know that you don't know and will be concerned of you seeming to already know all the answers. They expect you to ask questions. Coming off like you already know is not good for your practice or the safety of the patient.

Exactly!!! Don't worry about appearing uneducated - you're NEW. Nursing isn't something you get good at overnight! It takes years, honestly. Your gut instincts get more fine tuned as you get more experience. But things like parameters for calling the docs - those are things you should at least get a handle on before your orientation is over. PLEASE ask these questions of your coworkers. Don't worry, you're not going to look stupid - you're going to look responsible.

I remember precepting someone who told me to my face that she didn't think she needed any more orientation, that she doesn't like people looking over her shoulder, and that she likes to just "get right into it." Well, she ended up weaseling out of orientation early, and I never trusted her after that. She had no clue sometimes, and that worried me. She acted cool and confident, and some people thought she was the cat's meow. I thought she was dangerous.

BETSRN · Feb 27, 2005

Hello - I have been an RN for about 2.5 weeks. I am currently in an orientation program for a tele/PCU floor.
I have some questions. I do not want to appear uneducated at work. But alot of things I just do not feel were covered in school or in text books. I have asked some questions, but get unclear responses.
How do you tell if a patient is going bad? I know I have gut feelings.....but when do I call the doctor? I don't want to call the doctor just because.....what are my key warning signs? I want to be able to provide the doctor with logical, objective observations that they may not have picked up on during their rounds. Do my instincts count?
When is a blood pressure too high?
When is a blood pressure too low? Is there a panic level?
What if there is a huge difference in the ortho B/P's? Do I call or just chart?
Is there any interventions I can do without a doctors order?
I know you call a code if someone is not breathing or no heartbeat. That much I did get out of school and BLS. But how do I know it is coming...... I had an instructor tell me she did not experience codes because of her excellent assessment skills. I was like *WOW*. She is super nurse. So too shall I strive........
Can anybody help me and my future patients?
Many thanks in advance.

You need to work VERY closely with your preceptor (you should have at least a 3 month orientation) and pose these questions to that person. Do not be relying on a posting site. Good luck. Take it easy. You have a ways to go and you'll get through it!