I am a nurse with just about a year and half experience as a working RN. My first position was working LTC/skilled nursing, and I absolutely hated it. I felt I didn't learn much and I was overwhelmed more and more everyday. I left and found a subacute RN position and so far I've been there a little over 6 months. I think it's a good job to get some decent experience, but I still feel like I have not progressed. I still feel as though I lack many critical thinking skills and I have many stupid moments that I look back at and ask myself why I didn't catch that or think of that. I have great support from my nurse managers and DON, but my self-esteem has greatly been affected. I find myself comparing myself to other nurses, and am amazed on how well they are able to catch on to changes in a patient's status and know the steps to take. Doing this makes me feel stupid. There are days I still have crazy anxiety going into work, but then there's days I feel like I can conquer the day and what comes with it.
My primary issue that I feel like I'm struggling with is critical thinking. Nursing school does not teach you how to critically think, and I know it sometimes takes longer for some, but as a nurse for a year and a half already, am I just slower, or is this something that will never come to me? I work on a subacute floor, where I can have up to about 16 patients if the unit is filled. I find it incredibly hard to keep eyes on all patients, know patient hx, background, etc. My med passes can sometimes be heavy, then having to deal with wound tx and doctor's orders, I end up feeling extremely overwhelmed at times, where I'm begin to rush to just get everything done. I work 8 hour shifts and I feel myself a lot of the times rushing to get it all time that I forget what the purpose of me being there and why I became a nurse in the first place. I feel as though if I were to work in a setting where the ratio is smaller, I would be able to take the time, learn my patients, and actually work on my nursing skills. Many of the times, I walk into the room, introduce myself, get vitals, do a quick look over, and move on to the next patient. Some of the patients, as sad as it is, I only see a few times in an 8 hour shift. It sometimes leaves me feeling unaccomplished and disappointed.
Regarding critical thinking, I had a patient the other day where I walked in and got vitals. I got a BP of 204/80, and an oral temp of 102.5. I rechecked manually and got 190/76. Looking at her diagnosis, she was admitted for septic arthritis, and was being treated with IV ABT. I assessed for pain, gave her her IV ABT, scheduled Coreg, oxycodone for pain, and Tylenol for pain. I figured her BP was raised because she was running a fever and was in severe pain, and after looking at her BP trends, she did usually run on the higher side. But seeing this high number put me in panic mode. I quickly notified my supervisor and told her we should contact the doctor. Granted she was on BP medications, but it was a relatively small dose, so I felt it was right to reach out to the doctor. The supervisor told me to recheck the BP, and temp in two hours before reaching out to the doctor. What is your take on this? I also feel like because I go into panic mode, my first reaction is to call the doctor instead of critically thinking and asking myself why this may be happening. Sometimes I jump at it before looking at PRN orders, or the patient's background and medical hx. I am also scared to make myself look like an incompetent idiot if I were to call the doctor unnecessarily. Thankfully her BP did decrease to the 130s, and her fever did break, but was I overreacting? I am scared to make a mistake, not take initiative, and feel like an idiot. I also still struggle with identifying situations that warrant a doctor's call versus me working through the problem myself. I feel as though I need to just stop, take a breath and critically think problems through. Any advice on this? I need to work on my self-esteem and not be so nervous.
Hi, I'm also a subacute rehab nurse with 16 patients. I have a bit of advice because it is a real skill to learn fast assessment and to choose the most critical things to report. The first thing I want to say is again you are exactly at the level you should be. Telling the Dr about a patient with temp 102 and BP over maybe 160 or so is warranted especially on a known sepsis pt.
I think the only thing I'd do differently is learn to think of what the doctor is going to ask you to do. That starts with the orders. Is the problem you are reporting a change in condition or is it a known symptom with orders in place to handle it? In your specific case, the pt had IV ABX, Tylenol (which reduces fever as well but you need specific order to give for that use), oxy for the severe pain, and your BP med. All these were ordered and administered. So unless you have orders stating to notify MD for certain parameters you addressed each of the problems. That's why your supervisor said to wait to report to the MD because then depending on the result the MD will know what to do next. The trick is to assess the patient and decide: how bad is it? Do I have orders in place I could address the symptoms with? Is it a new problem or known?
Now on your unit things may be different but the supervisor on mine is another RN and is there to help the floor nurses with situations that pop up and communicate with the MD if needed. In your case, I would've done what you did and let the sup know that my pt was XYZ and I have these interventions that addressed the issues and if she could think of anything else I need to do. The other thing is at my work we have faxing for non emergent MD notification. I'd have faxed a brief summary and then when I got favorable results just faxed over confirmation that the patient returned to WNL. If not then you can call and say interventions didn't work what would you like next.
The other thing is learning to assess the information you have to come to conclusions about how healthy they are or aren't. You're only in the room a couple times a shift but even so you have more info than you think. You have their vitals, by talking to them you know if they are alert/oriented, if they are brand new to you the previous shift can give you a rundown on their baseline behavior, you have their med list and medical hx to tell you what problems they have that you are treating them for. That last one is a biggie. Lots of my new nurses get so caught up by the number of patients and the flow of med pass they forget to ask or know why is the patient here? What are we treating them for? What health goal are we trying to reach. Mostly the answer is PT/OT but lots of times we get patients with active infections to manage, wounds to heal, sometimes they have secondary problems like a fall at home sent them here for pt/pt but they have high blood sugars or dialysis so we are managing those chronic health conditions while they are with us. Critical thinking is a big scary term that intimidates a lot of new nurses bc they feel like it means something extra special. But no matter what level of nursing you are in your job is task and goal oriented and a lot of each job is a learning curve of what facts you need to know and then how to use that to address the patients problems. I learn my patients by seeing them everyday and checking in when I do my rounds. I can tell from planning ahead which pts are more dicey than others and may need careful monitoring. Active infection, active sepsis, with IV ABX is a priority over a pt recovering from a hip replacement who has routine pain medication. But if my formerly walky, talky hip replacement pt is lying in bed, lethargic, not able to communicate well, and just feels listless then I know from the door I need to investigate bc that is another change in condition. Might need to look for infection at the surgical site. The more you do it the more you'll learn to recognize the signs and the more you ask questions the more you'll learn what to do when you see those signs.
Don't worry about looking like an incompetent idiot and being afraid to report on things. When I train new nurses I am much more worried about ones who are impulsive and think they know exactly what to do without asking first if they have doubts. I've seen new nurses straight up not know how to do something and just wing it without a plan and when that happens no one can save them from the outcome bc no one knew what was happening until it was too late. Always communicate with someone when you're feeling unsure. That can be other floor nurses, your supervisor or even the doctor. A truly incompetent nurse is one who cannot admit to their shortcomings and tries to push through anyway without asking for help. People might be annoyed if you ask every time but remember you have lots of questions now but one day you'll find you have the answers because you've seen or experienced the problem before. It feels like it won't but I promise it will.
The last piece of advice I have is stay organized! Before I start my shift I have a paper that has each pt, their reason for being there, important dx, and details like if they have lines, ports, drains, IV fluids or meds, fluid restrictions, oxygen, if they can take WP, if they're diabetic, who is the Dr. I build it through out my time and update it each time I get a new admit. The second sheet I have organizes what time the meds are due. I have 2 med passes so I organize what they need in 1st pass or 2nd. Do they need both? Just one or even more frequently? Any treatments? I'll put if they need insulin or bs check. Or if I need to watch the clock for PRN pain meds. Then I use that list as my checklist and use that to manage my time. I'll know who needs what and when at a glance and check them off as I go without only relying on the MAR.
Create your own strategies for organizing yourself and helping decide your priorities. I'm a visual person and I have an awful memory so I have to write things down and have a place to check them off and add thoughts. So if fast things happen like a random verbal order or stat labs I can write them down next to the person name on my to do list. You'll find whatever works for you and you'll have more confidence if you feel like you have some kind of plan for how the day will go.
Nrsingtakesheart
1 Post
Hi, I'm also a subacute rehab nurse with 16 patients. I have a bit of advice because it is a real skill to learn fast assessment and to choose the most critical things to report. The first thing I want to say is again you are exactly at the level you should be. Telling the Dr about a patient with temp 102 and BP over maybe 160 or so is warranted especially on a known sepsis pt.
I think the only thing I'd do differently is learn to think of what the doctor is going to ask you to do. That starts with the orders. Is the problem you are reporting a change in condition or is it a known symptom with orders in place to handle it? In your specific case, the pt had IV ABX, Tylenol (which reduces fever as well but you need specific order to give for that use), oxy for the severe pain, and your BP med. All these were ordered and administered. So unless you have orders stating to notify MD for certain parameters you addressed each of the problems. That's why your supervisor said to wait to report to the MD because then depending on the result the MD will know what to do next. The trick is to assess the patient and decide: how bad is it? Do I have orders in place I could address the symptoms with? Is it a new problem or known?
Now on your unit things may be different but the supervisor on mine is another RN and is there to help the floor nurses with situations that pop up and communicate with the MD if needed. In your case, I would've done what you did and let the sup know that my pt was XYZ and I have these interventions that addressed the issues and if she could think of anything else I need to do. The other thing is at my work we have faxing for non emergent MD notification. I'd have faxed a brief summary and then when I got favorable results just faxed over confirmation that the patient returned to WNL. If not then you can call and say interventions didn't work what would you like next.
The other thing is learning to assess the information you have to come to conclusions about how healthy they are or aren't. You're only in the room a couple times a shift but even so you have more info than you think. You have their vitals, by talking to them you know if they are alert/oriented, if they are brand new to you the previous shift can give you a rundown on their baseline behavior, you have their med list and medical hx to tell you what problems they have that you are treating them for. That last one is a biggie. Lots of my new nurses get so caught up by the number of patients and the flow of med pass they forget to ask or know why is the patient here? What are we treating them for? What health goal are we trying to reach. Mostly the answer is PT/OT but lots of times we get patients with active infections to manage, wounds to heal, sometimes they have secondary problems like a fall at home sent them here for pt/pt but they have high blood sugars or dialysis so we are managing those chronic health conditions while they are with us. Critical thinking is a big scary term that intimidates a lot of new nurses bc they feel like it means something extra special. But no matter what level of nursing you are in your job is task and goal oriented and a lot of each job is a learning curve of what facts you need to know and then how to use that to address the patients problems. I learn my patients by seeing them everyday and checking in when I do my rounds. I can tell from planning ahead which pts are more dicey than others and may need careful monitoring. Active infection, active sepsis, with IV ABX is a priority over a pt recovering from a hip replacement who has routine pain medication. But if my formerly walky, talky hip replacement pt is lying in bed, lethargic, not able to communicate well, and just feels listless then I know from the door I need to investigate bc that is another change in condition. Might need to look for infection at the surgical site. The more you do it the more you'll learn to recognize the signs and the more you ask questions the more you'll learn what to do when you see those signs.
Don't worry about looking like an incompetent idiot and being afraid to report on things. When I train new nurses I am much more worried about ones who are impulsive and think they know exactly what to do without asking first if they have doubts. I've seen new nurses straight up not know how to do something and just wing it without a plan and when that happens no one can save them from the outcome bc no one knew what was happening until it was too late. Always communicate with someone when you're feeling unsure. That can be other floor nurses, your supervisor or even the doctor. A truly incompetent nurse is one who cannot admit to their shortcomings and tries to push through anyway without asking for help. People might be annoyed if you ask every time but remember you have lots of questions now but one day you'll find you have the answers because you've seen or experienced the problem before. It feels like it won't but I promise it will.
The last piece of advice I have is stay organized! Before I start my shift I have a paper that has each pt, their reason for being there, important dx, and details like if they have lines, ports, drains, IV fluids or meds, fluid restrictions, oxygen, if they can take WP, if they're diabetic, who is the Dr. I build it through out my time and update it each time I get a new admit. The second sheet I have organizes what time the meds are due. I have 2 med passes so I organize what they need in 1st pass or 2nd. Do they need both? Just one or even more frequently? Any treatments? I'll put if they need insulin or bs check. Or if I need to watch the clock for PRN pain meds. Then I use that list as my checklist and use that to manage my time. I'll know who needs what and when at a glance and check them off as I go without only relying on the MAR.
Create your own strategies for organizing yourself and helping decide your priorities. I'm a visual person and I have an awful memory so I have to write things down and have a place to check them off and add thoughts. So if fast things happen like a random verbal order or stat labs I can write them down next to the person name on my to do list. You'll find whatever works for you and you'll have more confidence if you feel like you have some kind of plan for how the day will go.
Good job, keep at it and keep asking questions!!