Be Thorough! Please!

[c.kelly20]

I just wanted to share my own experience and hope it will benefit other new nurses.

I recently passed the NCLEX-RN and started my job on a med/surg unit. I knew going in that this job wouldn't be an easy one and I was terrified given the patient load I would have (7-9 patients per nurse, compared to the whole ONE patient I would be given on clinical). On my 4th day, I was already taking on 5 patients on my own, with some guidance of my preceptor.

I received report on a patient from the night shift nurse -- we'll call him Patient X for HIPAA reasons. Patient X had an oxygen saturation in the 87-89% range while on high-flow O2 due to fluid around his right lung. I also receive in report that the patient had a Stage 2 pressure wound on his coccyx. The night nurse proceeded to tell me that it had been looked at upon admission during the night, had a dressing covering it, and that the wound was red/weepy.

I receive word that he is being sent for a thoracentesis to drain fluid off of his lung and then being moved to another floor, where he can be more closely monitored. I began my morning as usual, prioritizing my patients and figuring out what order I would be seeing them in. I choose to see Patient X first as he is my most 'critical' patient and he is leaving me shortly.

I enter Patient X's room, give him his morning medications, and quickly rush through my assessment as I can see that his breathing isn't all too great. I checked on him, listened to his heart and lungs (diminished as expected), checked for edema and sensation around his feet, and asked if he needed anything before he left me. He declined, and I left the room, preparing to finish charting and get ready to give report to the receiving unit.

Can anyone see what I missed here??

First of all, the assessment I performed was much shorter than any assessment I learned in nursing school. But, it was the one my preceptor had done on all of our patients on my first day, so I went with it. Mind you-- this was on day 4 of me working as an RN, ever. He was 1 of 5 patients I had, my preceptor wasn't in the room, and I was so busy feeling rushed/overwhelmed/concerned that morning, that I completely forgot to check the pressure ulcer on his backside. While this isn't necessarily 'priority' given the condition he was in, I still should have checked it.

It wasn't until the patient left the unit and I was finishing my computer charting on him, that I get to the 'skin' section and think "CRAP. I forgot to look at that." I based my charting off of the previous nurses' report to me, hoping he had been accurate.

A few hours later, my boss gets a phone call from the receiving unit, stating that Patient X had a pressure ulcer on his backside that was "dirty" with "pieces of things from home in it". It had NOT been looked at upon admission to the unit like I was told. The ultimate fault lies on the admitting nurse, with me following suit for 1) basing my charting off of his report, and 2) not fulling assessing the patient.

So, why am I telling this long story?

1) Be THOROUGH!!!

2) Take it as a lesson. I felt overwhelmed with a patient load that size and given how busy I was, I should have spoke up. It is NEVER safe to rush through an initial assessment. Never, ever. Safety first. The patient's safety and care is FIRST.

3) Do NOT base your assessment off of the previous shift's assessment. Patient's conditions can change. The nurse might be lying. The nurse might be wrong. Whatever the case, always do your OWN assessment.

4) My boss automatically began to scold my preceptor (whom, if you remember, wasn't in Patient X's room at the time) -- I spoke up, and took blame for it myself. It SUCKED having to do that, but it was MY fault. If you make a mistake, FESS UP. We are new and learning, and unfortunately I had to make a mistake like this to learn it, but always speak up and own your mistake. Don't let someone else take the fall, especially if that someone is your preceptor for 6 weeks.

I really hope someone takes something from this. My patient load yesterday was 7 and it was day 5 for me. I didn't learn anything, felt behind, and got out late because of charting. I will be telling my preceptor that I need to step back to 3-4 patients and gradually work up to more, because I still felt my assessments were rushed. I'm only in week 2 so I'm hoping to improve.

Good luck out there and be SAFE!

[HouTx, BSN, MSN, EdD]

I'm sure that you will never make this mistake again - a very valuable lesson.

As time goes on, your ability to prioritize will continue to improve - and this is the basis for effective time management. In the meantime, try to remain firm in your boundaries - continuing to do the 'right' thing rather than adopt shortcuts and work-arounds that your coworkers may be using.

Hey, if you were able to care for 7 patients on day 5, you're doing great!!! Don't sell yourself short.