Common Sense Nursing?

[VivaLasViejas, ASN, RN]

Last night I floated to the OB-GYN floor, as I often do, and walked right into a near-disaster: a suddenly obtunded 29 year-old vag hyst patient with a respiratory rate of 7 and 02 sats in the upper 70s. And how she came to be that way reminded me, yet again, why I hesitate to take a job on that unit even though I love working there: the lack of basic nursing knowledge and skills among the regular staff.

I was just outside the room, writing down the pt's information on my worksheet, when the off-going shift nurse grabbed me and said "I think I need some help here!" I mean, this pt. was out of it---she was arouseable only if you shook her and yelled her name, what little speech she had was unintelligible, and her respirations were shallow as well as infrequent. And I had this nurse looking at me like, now what the hell do we do?

Of course, the first thing I did was grab an 02 setup and put it on, which improved the pt's sats almost immediately, and got a set of vitals, which were more or less OK. That's when the nurse confessed to me that she'd just given 100 mg. of Demerol w/ 50 of Phenergan *IV*

She said "Well, I thought it was a lot to give IV, but I went ahead and did it anyway because she was in so much pain". I couldn't believe it. I've never given more than 25mg of Demerol via that route, especially not with that much Phenergan!! We got the patient stabilized pretty quickly, thank God, but then I had to walk this nurse through the entire follow-up. I actually had to tell her to call the MD to report what had happened, and to write an incident report. (I ended up doing the progress note myself because she forgot.)

Luckily for all concerned, things turned out well, and the small amount of Narcan I gave the pt. made her come around without completely undoing her pain control. But it makes me wonder, not for the first time, what happens to some nurses who go into specialty care that makes them completely forget the basics. Common sense should tell you NOT to give 100mg of Demerol through an IV line, just as it should tell you NOT to ignore the little voice telling you to question something. It wasn't even busy on the unit, so there was no excuse for it.......and when I looked at the MD's original order, I saw that while it was scrawled, the order stated the dose was to be given IM. (Someone had transcribed it onto the MAR wrongly as IV.)

Then, the nurse didn't even know what to do for the patient when her sats went into the toilet.....how much critical thinking does it take to run for the oxygen?? Her reason for not doing so was, "I've never had a patient de-sat like that before". I'm sorry, but even when I was a CNA I knew enough to grab the 02 equipment at times like this.

The stink of it is, this girl isn't the only nurse I've encountered on that floor, or elsewhere, whose grasp of the basic nursing skills we all supposedly learned in school is tenuous at best. Some of them haven't started an IV or given insulin in years. They don't change the team worksheets as patients' conditions change. They don't even know how to change a central line dressing or give blood transfusions (I've literally had to walk OB nurses through the entire procedure).

I hope this doesn't sound like I'm superior just because I knew how to handle the situation, but somebody not knowing the nuts-and-bolts stuff is just incomprehensible to me. It's just common sense nursing that we're all taught in school.......how tough is that??

[SmilingBluEyes]

hope you filed an incident report. that's the only way stuff like this will be addressed.

[VivaLasViejas, ASN, RN]

Yep.....only I made HER write it up, and I wrote the progress note in the patient's chart as to what happened, the MD notified, and pt's response to treatment. No way I'm not gonna cover MY behind!

[P_RN, ADN, RN]

That is some kind of scary situation. Other nurses floating there along with you need to push it up the chain of command. TPTB need to address this.

Unfortunately I HAVE given 100-150 of Demerol IV -yes 100-that's right.....we had one doc who had multiple SSC patients, and that's what he ordered....sometimes q 2h. We finally convinced him to put his foot down and order Dilaudid after one of his patients seized and hit his head on the lavatory and got a head injury....

But back to the subject....how can they NOT have given insulin or started an IV? Sheesh I wouldn't want MY daughter giving birth there.

[VivaLasViejas, ASN, RN]

These gals are so pampered, they have a bad reputation all over the hospital. They whine to the nursing supervisor when they have more than 2 or 3 patients, and being a specialty unit, they get all the staffing they need, even if it means pulling a nurse from med/surg and exacerbating the staffing problems there.

Of course, I exaggerate a little when I say they haven't done the most basic of nursing tasks in years.....but only a little. They are completely lost when they float to med/surg (like THAT happens very often). They don't do their 24-hour chart checks half the time, so labs & diet changes get missed; they leave the original stuff on the team worksheets so long that when I come up for a shift, I'll look at the information thinking I've got a fresh post-op who's still on clear liquids and Q 4 hour vitals, has D5LR going and a Foley, when all I've got is a patient who's ready to go home in the morning---no IVs or tubes, eating regular food, passing flatus and so on. And as I said before, they are clueless when it comes to dealing with things like blood administration, wound care, central lines and so on.

Now, I love working on this unit, it's MUCH easier on me physically than med/surg, and I enjoy caring for healthy moms, and especially the babies. I get along well with both nurse managers, and I've even been asked to consider making the unit my home at some point. But I feel like I'd have to clean things up and make people get better organized, and that would NOT be my place.

By the same token, there's a lot of stuff I don't know about L&D, and I'd be equally lost trying to figure out what those decels mean, or assisting in the C-section room. But I still don't understand why, when we all go through basically the same type of RN program, some so-called specialty nurses forget the basics!

[hmccartn]

Thanks for the post. I am a student currently considering becoming an OBS nurse...I hope it is not common to lose basic skills when working in the area. Do you have any suggestions about maintaing some of those skills once i graduate. I prefer not to float or if i do, would like to float between OBS and antenatal or gyne surgery recovery..

[kevcam]

Originally posted by mjlrn97

They don't do their 24-hour chart checks half the time, so labs & diet changes get missed; they leave the original stuff on the team worksheets so long that when I come up for a shift, I'll look at the information thinking I've got a fresh post-op who's still on clear liquids and Q 4 hour vitals, has D5LR going and a Foley, when all I've got is a patient who's ready to go home in the morning---no IVs or tubes, eating regular food, passing flatus and so on.

Wow I think we may work at the same hospital... You've summed up very nicely something I've been PO'd about for quite a long time at my place of employment.

[jnette, ASN, EMT-I]

Thank you for this thoughtprovoking post, mjlrn.

It is for this VERY reason that I am orienting in med/surge now... even if only for future prn once a week. I'm not doing this to work my butt off (I do that in Dialysis already, thank you !) ; not to increase my income. No... but to increase my KNOWLEDGEBASE.

Although really still a "new grad", I have been doing dialysis ONLY for the past six and one half years. While dialysis certainly has its own challenges, there is soooo much that I felt I was losing by not utilizing the mutiple other skills I needed to stay in touch with in nursing as a whole. That's not to speak of ALL the hundreds of medications, and the ever increasing list of NEW meds which I have no opportunity to familiarize myself with at dialysis.

It really began to bother me. I knew that if I did not get out there on a unit in a "real hospital" soon, I would quickly lose all I had worked so hard to learn. If my nursing skills were then ever to be called on in an emergency, or in a disaster, would I know what to do ? It was a risk I was not willing to take.

So while I'm great at "sticking", all the varied catheters and their care, monitoring electrolytes and dialysis specific labs, and the consequences of diabetes and hypertension... I did not wish to leave my self short. I felt I would be cheating myself and even potential patients if I did not come out of my own little "box" and soak up all the knowlege that's out there for nurses today.

So thank you. For reminding me once again why I'm doing this. :)

(and YES... I DO feel "stupid" and incompetent still on the "unit". I'm sure these other girls think "WTF" ??? She doesn't even know how to take off orders!) uh.... no.... I DON'T ! Never have to do that at dialysis... or deal with admissions and discahrges, NGs, foleys, surgical post-ops, etc., etc., etc. The list is endless.

Yep. Gotta do this. Thanx again for the reminder why... and the motivation. :kiss

[Agnus]

Right out of school I went into critical care. a great advantage. As a new grad my skills and knowlege were sharp. It was all still very fresh for me having just finished school. After 2 yearsRN (and one year LPN in the same setting) my hospital closed and I went to home hospice. Been there for 6 months and am feeling like I have forgotten some very important and basic stuff. Scarry.

[VivaLasViejas, ASN, RN]

I think it's really important for nurses who are NOT working at the bedside to take continuing education courses, preferably ones with a practicum. I did this while I was in LTC administration, and I think it's the only thing that saved my bacon when I went back to direct care. I also insisted on keeping up my clinical assessment and technical skills.....for one thing, not ONE of the RNs at one facility I worked at could start an IV worth beans, so whenever some troubleshooting needed to be done, I was the one they called to come in and deal with it.

I also think it should be mandatory that ALL nurse managers work at least one 8-hour shift on the floor every month......not only would this help them keep up their skills, but they'd KNOW what can and cannot be accomplished out there with the kind of staffing and the kind of patients we deal with every day. I've been on both sides of the desk, and I personally have much more respect for the manager who pitches in and helps, than the one who's been out of bedside nursing so long that she actually can't relate to what we go through trying to keep everything together without either going crazy, or accidentally killing someone.

[SmilingBluEyes]

Originally posted by hmccartn

Thanks for the post. I am a student currently considering becoming an OBS nurse...I hope it is not common to lose basic skills when working in the area. Do you have any suggestions about maintaing some of those skills once i graduate. I prefer not to float or if i do, would like to float between OBS and antenatal or gyne surgery recovery..

it's not that common----at least where I work. And I have found plenty of imcompetence in MED -SURGE too, when I floated there in the past. Let's dont' turn this into a "us versus them" thing, slamming OB nurses or any other so-called "speciality nurses". Med-surge IS a speciality in itself and accountable just as the rest of us......

Just do what YOU can to remain competent and current. NOT ALL OB-GYN nurses are incompetent ignoramuses, as one might be lead to believe in this thread.....

[SmilingBluEyes]

Originally posted by mjlrn97

I think it's really important for nurses who are NOT working at the bedside to take continuing education courses, preferably ones with a practicum. I did this while I was in LTC administration, and I think it's the only thing that saved my bacon when I went back to direct care. I also insisted on keeping up my clinical assessment and technical skills.....for one thing, not ONE of the RNs at one facility I worked at could start an IV worth beans, so whenever some troubleshooting needed to be done, I was the one they called to come in and deal with it.

I also think it should be mandatory that ALL nurse managers work at least one 8-hour shift on the floor every month......not only would this help them keep up their skills, but they'd KNOW what can and cannot be accomplished out there with the kind of staffing and the kind of patients we deal with every day. I've been on both sides of the desk, and I personally have much more respect for the manager who pitches in and helps, than the one who's been out of bedside nursing so long that she actually can't relate to what we go through trying to keep everything together without either going crazy, or accidentally killing someone.

excellent post. THIS really sums up some excellent solutions without finger-pointing or denegrating things to an "us versus them" situation, all too common in nursing. I LOVE your ideas here.