Discernment (LONG post)

Virgo_RN, BSN, RN · Jan 8, 2008

I&Os: I'm confused. What do you meant they're not being recorded properly?

CNA: Maybe she really *was* busy. When I was a CNA, there were times when I had to say no to an RN. I didn't like to do it, but sometimes things were so busy that I had no choice. I am only one person, and cannot be in all places at once. However, I know of some CNAs who are just uncooperative. I can't tell which category the CNA you work with fits into.

NG Tube: I've never inserted an NG tube, but if I did, I would explain the procedure to the patient first (even if they had already had one) and arrange a signal for them to give if they needed me to stop. If they gave the signal, I'd stop, then when they were ready, advance the tube some more. Unless the patient is unconscious or very confused (to the point where they cannot cooperate), NG tube insertion should involve cooperation between the nurse and the patient. You don't just stuff the thing in there. I think you handled the situation just fine, and now for future reference, you know what you will not do in your practice as a nurse.

The patient who fell: Since you were the one to discover the patient on the floor, you probably should have filed an incident report, if that is your facility's policy. As far as what to do next, you could have assisted the patient to the bathroom/with the bedpan yourself, or put on the call light for the aide to come, and told the patient someone would be with him shortly. Before getting any patient out of bed that you do not know, it would behoove you to check the chart for the activity order. If still unsure, just explain to the patient that you don't feel safe getting him out of bed, and that you would be happy to help him with the bedpan, or he could put on his call light and wait for his nurse/aide. Give him the choice.

....ooooorrrrr (and/or?), you could report the nurse.

Confidence: Personally, I'm hoping it comes with experience.

nursemike, ASN, RN · Jan 8, 2008

First, in terms of night shift and physiology: It does take your body some time to adapt. We are not nocturnal animals by nature. In terms of your dietary issues, I'd suggest carrying some light snacks in your bag--you do have a bag, don't you? Everybody needs a bag. I'm a guy, so mine looks like a briefcase--actually, more of a messenger bag--but it's a purse for all intents and purposes. I don't recommend fast carbs like candy or fruit juice. You aren't hypoglycemic, you just feel that way. So a little bit of complex carbs and protein will help keep the shakes and blahs away without spiking your glucose. Also, my facility says we get a half-hour for lunch and fifteen minute breaks for each four-hour block, but, generally, it isn't a problem if you replace one fifteen minute break with three five minute breaks. Sometimes all I need is just a little breather to get off my feet and drink some water or coffee. Other times, I do need to get away from the floor for ten or fifteen--I've been taking fewer of these since I've been trying to quit smoking, but if the stress gets severe, I'll take one as soon as practical (and usually wind up smoking one cigarette).

I think you hit the nail on the head with your other concerns: confidence. It's hard to be an effective patient advocate when you are busy coping with your own anxieties. But nursing is all about setting prioroties, and I don't think it's unreasonable to make your first priority getting more comfortable in your role. Standing up for your own or someone else's patients takes courage, but for a new nurse, just showing up for work takes courage. The things you object to would be happening if you weren't there. If you are there, you can change them, but if you don't survive your first year, you won't be in any position to make a lasting change. By all means, step up to the plate when you are able, but I don't think you need to feel too badly if you aren't quite ready, just yet. I was a timid a newbie as has ever been seen, and while I'm no Nurse Ratched, today, I've learned to be more confident in my judgements. Sometimes I have to take a deep breath and remind myself to Be The Nurse--and sometimes it actually works!

I hope you are fortunate to work with some nurses you respect. If so, I suggest forming "alliances" and learning as much as you can from them. I'm not advocating cliquishness, but there may be nurses you see doing things the way they should be. Getting acquainted with them and being able to discuss your concerns informally is more than a chance to "blow off steam," it's a chance to learn how they've handled similar situations. I have a few friends who are aides, and it amuses me to no end to tell them I've learned a lot from a fellow nurse who is a bit notorious among the aides for "over-delegating" (in the aides' opinions). But I have learned a lot from her, and when I find myself up to my...let's say hips...in alligators, I don't sweat so much about the aide who is up to her knees in snapping turtles. It's all about priorities, and I'm doing triage with every med pass. I've literally gone into a confused patient's room thinking I'll give the Dilantin first, then the metoprolol, so if they start fussing after 3 or 4 pills, all I'll have left ungiven is the Pepcid and Colace. Or I'll leave the patient who needs meds in applesauce last, so at least my other patients get their meds on time.

I hope this doesn't sound like permission to shirk your responsibilities, but I do think all of us--especially newbies--have to apply triage principles to ourselves. Identify the most urgent concerns, fix as many of those as you can, but if the resources aren't there to fix some problems, set them aside and focus on what you can do.

Indy, LPN, LVN · Jan 8, 2008

You need to carry snacks in your pocket, it sounds like. Maybe not a lot of snacks, but something so that when "it" hits you cram it in your mouth and keep going. It looks funny but not quite as funny as you hitting the floor.

Ditto nursemike's advice on what kind of snacks.

On the patient who fell: Sounds like you wound up doing a lot of someone else's work, and right when you were having blood sugar issues too. Ick. Once the nurse knows, you need to leave the room before the patient's nurse does. Like, if the patient isn't injured and doesn't need lifting, etc. You can say things like "are you good now?" or "you okay?" to the nurse, not to the patient, to sort of show that you're helping the nurse there... sometimes the patients/families can then tell who their nurse is. If you hang around they're just gonna want you to do more stuff. Do what you need, get out, cram snack in your face, take a deep breath, and see where you are from there.

Every nurse is going to handle their own patient load differently. If you don't see the nurse actively contributing to conditions that will create yet another fall, let him/her do it their way. When you get as far in as to figure out what someone else's patient needs based on your assessment, especially if that nurse is already out the door, you're in effect, taking over the patient. Now this is NOT always a bad thing, not always necessary either. In some cases you must do this or the other nurse will miss an impending medical emergency! Time and experience will teach you when to just walk away and make sure you remember to eat.

I'm a little loopy right now, staying up instead of sleeping (can't miss UPS today), so I apologize if I'm incoherent.

lorilou22RN · Jan 8, 2008

Oh boy you certainly have some issues with confidence. You do sound caring and thorough which are very good traits that are somewhat missing from the healthcare field. Confidence will come over time. As far as your mentor saying you are slow, well that is a time management issue, and perhaps your thoroughness is slowing you down. Now I am not stating that you should not adequately assess a fallen patient, but you can do a quick once over, call for help, and get him back to bed. If the patient is awake, don't ask who the president is! That is up to his primary caregiver. If he can tell you why he is on the floor, that is all I would need to know. As far as the NG tube, you need to really explain to the patient why this is needed. If you don't recieve any cooperation, then wait until later, then try. You probably need to become a bit aggressive/assertive in your personality. That is the only way to adequately survive in the nursing field. Remember the Docs rely upon you to get the patient thru the nite, and if you doubt yourself, they will doubt your ability. Once the Docs and your peers realize that you aren't sure of yourself, they won't trust your judgement.

It will take up to a year to truly get the hang of things, and develop your practice, this is a hard time.

One more note, your shift starts at 1900, the I/O's from 15-19 are out of your hands so let it go.

nursemike, ASN, RN · Jan 8, 2008

The OP has expressed several concerns, any one of which could be food for an entire thread--and probably has been. The relationship between nurses and CNAs (PCA's, techs, NA's--whatever the actual title) has been discussed elsewhere, sometimes heatedly. It remains, however, one of the major challenges for new nurses, and I'd like to add some thoughts on the matter.

First, I usually use the term "aides" on these boards. Where I work, a CNA certificate is not required, so most cannot properly be called CNAs. At work, I use the official title, but it's specific to my facility and wouldn't make sense to a lot of readers. So I say "aide," with no intention to be condescending--it's a difficult, important job, and I do respect those who do it. I don't expect an aide to be subserviant to me, although they are by definition subordinate. Properly delegating to my subordinates is as much my responsibility as passing meds or assessments. It can certainly be done in a civil, collegial manner, but it has to be done.

I'm lucky to work with some very good aides who are smart, hard-working, and committed to patient care. They make me look better than I am. I've rarely worked with ones who were just bad--looking to avoid anything they could get out of, lazy, inept--and usually the very ones who want to tell me what to do. (I'll take advice gratefully from a good aide, but I don't take orders from any aide.)

A lot of the time, though, I find myself working with well-meaning, conscientious people who do a good job, but are in need of some direction. This isn't nearly as miserable as working with someone who is bad, but in some ways, it's trickier.

For example, occassions ahve arisen where I've needed a set of vitals right away because a patient's condition had changed, but when I call the aide, she's busy. If she's busy with a bath, or toileting another patient, I get the vitals myself, or get another nurse to get them while I do whatever I need to be doing. Fair enough. On the other hand, I sometimes get a call to help a patient toilet because the aide is busy doing something like routine vitals--the rounds they do every four hours. Also fair enough, unless I'm doing something like a med pass or a dressing change, or something else more pressing than routine vitals.

In that case, I need to be able to communicate to the aide that the routine task can be interrupt so that the emergent one can be addressed. So if I ask an aide to do something and she (or he) is busy, I ask what they are busy doing (actually, most tell me before I ask). Then it's up to me to decide who is best in a position to handle the bedpan or whatever I'm calling about. It has nothing to do with being too proud to do "aide's work," but some aides have a tendancy to develop a routine to get their work done more efficiently (good) but may not appreciate the need to break with the routine to address specific problems. Or they may think I'm doing something routine, like charting, and might be better able to drop what I'm doing than they are. (Anyone who has worked with me awhile knows I'd rather do colostomy care than chart, but I will delegate in order to chart if the aide is just chatting or reading a magazine.

Some aides on my unit team up to handle baths and other tasks that require more than one person. Some seem to feel it's the nurse's job to help with baths. I'm fine with helping, when I have time, but I can't drop a lot of the things I'm doing because the aide is ready to do a bath. They can get another aide to help, or wait until I'm available--either is fine, as long as it's understood that I'm not there as the aide's assistant. But, again, with anyone who is any good at all, that point can be made without getting nasty or bossy. Usually, all it really takes is that old bugaboo--confidence. If you act like you are in charge, you can do it politely, but if you seem indecisive, you may or may not get the respect you need to be effective.

I once told one aide that she was just lazy enough to be perfect. She did everything that was required of her quickly and efficiently, and if I needed something extra, I knew just where to find her looking through an Avon catalog or gossiping with her co-workers. I meant what I said. I've worked with others who are always busy, busy, busy, and never available when I'm trying to wrassle a confused little-old-lady back into bed. I've also been fortunate to work with experienced aides who "handled" me the way I've seen some experienced nurses "handle" newbie doctors--a helpful suggestion made in a way that it (almost) seems like it was my idea in the first place. God bless 'em.

RiverNurse · Jan 9, 2008

Thanks all - for all your advice... and one last word from our sponsors about I&Os... and blood sugar...

Letting go of the I&Os from 1500 to 1900 was my initial response - until my preceptor told me it was my responsibility to ensure they were recorded correctly - from 1500 to 2300. My initial response was, "Eh?" Then I began to doubt myself some (yeppers, a real confidence issue here).

Anyway, glad to know that I am/was on the right track.

Oh, I had access to a meter today and decided to check my blood sugar before meals. 0700: 153, 1200: 202, 1730: 173 - just prior to each meal, nothing between meals except water or sugar free drinks.

I have a doctor's appt on Thursday. Once again, thanks, all...