New nurse and critical patients

[fencer1119]

Hi I am a fairly new nurse. Graduated from school a year ago and was hired into the ER straight away. Been on the floor for 11 months and on my own the last 5 or 6. I work at a community hospital with a fairly sick patient population, not a trauma center.

I feel like I'm okay with the normal run of the mill stuff, but I am still terrified of critical patients and I know that I need to grow A LOT in this area. The issue where I feel most unsafe is when it comes to managing multiple drips and medications. I found myself in a situation the other night where the entire ED was slammed, acuity was high, tempers were short, and help was slim, and I was getting multiple patient's that were very sick requiring medications I'd never given before, plus others I have had limited experience with. I felt so uncomfortable and had so many questions, but was afraid of annoying the my overtaxed coworkers. I felt paralyzed by the whole situation. I found the pharmacy was no help (asking how to give glucagon for beta blocker overdose - told me to read the directions in the box, which were only for hypoglycemia so they were less than helpful). Also had to give cardene for the first time (patient was in hypertensive crisis secondary to cocaine toxicity) and the drip book was nowhere to be found so I could even figure out how to mix it. Was told to switch the cardene to nitroglycerin - can I just turn the cardene off or does it have to be titrated down first? Just some examples of my questions. Other nurses either didn't know the answer, or told me information I now question after I got home and googled it. For example the charge nurse had me start the cardene at 0.5 mg/hr and titrate up by 0.5mg, but I later read to start at 5 and go up in increments of 2.5. Or was the 0.5 appropriate because he was a renal patient? All I know is the guys blood pressure didn't budge and I had to ignore my other patient's for about an hour while i played with one medication.

I felt like I needed my hand held all freaking night - and yes I'm inexperienced but I should be doing better than this! Left work with no self-confidence worried about being a bad nurse and unsafe and thinking I need to give up ER nursing (but it was my dream and I've barely started!). When I am dealing with these high risk medications I feel like a caveman blindly swinging a club, but I don't have the knowledge or finesse to manage everything that is going on, or even recognize where I could get into trouble. I get the inkling that some other nurses just hang the meds, keep the vitals stable and don't worry about anything else - let the ICU finesse everything. Is that really our role with critical patients in the ED and the best I need to do? Or am I overthinking to the point where I'm ineffective. I feel like I don't know what I don't know, therefore I don't know what questions to even ask (a mouthful, I'm sorry).

So I guess what I've come up with a long winded way of asking what resources are out there for learning how to manage the critically ill patient with multi-system issues - specifically medication centered? And given the situation above, what other things am I missing and what other things could I include in my "action plan" to improve? How do I conquer this crippling self doubt? Any advice would be welcome. Thanks!

[FlyingScot, RN]

I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.

And as a nurse you should be aware of your scope of practice and abide by it or else you won't be a nurse for very long.

Listen, I'm not an idiot order follower. I used to RUN codes. I know standard dosing but I always clarify instead of guess and when I was new I made damn sure I had an order and KNEW about the drug I was giving. The OP was essentially left on her own to muddle through a situation without the experience or support she needed. This should never have happened.

[Do-over, ASN, RN]

I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.

I'd agree more with this post if you had stated "as an experienced nurse with experience running drips you should know that..."

As a new or green nurse, you would have no idea how to handle it, and multiple drips would only add to the problem.

[sevo87]

I agree with most of what you guys have said. You are right that I should have prefaced my statement with "as an experienced nurse", I'm not implying that a new grad should or would know what to start the drip at. However, unless I read it wrong didn't they state that they have a 5-6 month orientation??? I have never heard of this, and if it is indeed the case I would've expected their preceptor to teach them this, among many other things. So I guess it's more of a failure on the part of their preceptor.

Also, I am well aware of what my scope of practice includes and does not include... thats why I went back to school. :)

[Do-over, ASN, RN]

5 or 6 months sounds like a lot of orientation, but depending on the hospital you might not get to see many patients that critical even on the unit during that time. And then, ER will likely either hustle those patients to the unit (and rightly so) or to another facility. Also consider that vented patients, or patients on multiple drips would be 2:1 on the unit (or 1:1). I would think that should be the case in ER, and even though you would still likely be too busy to do a lot of research at least you can focus on that one situation.

[87RN]

You should look up your hospitals P&P for drips, if the ED doesn't have a copy, try going to ICU and see if they have one. My ICU has a reference binder with info on all the gtts with starting rate, max rate, etc. I have a little card laminated that I carry with me with all the info. Also on your days off, study your drugs, learn what they are for, how they work, the half- life, etc. Our MD's give us verbal orders and expect us to know how to titrate them they usually just say "start them on ____ drip". If your patient is being started on multiple drips you need to ask your charge to change your pt ratio and work on getting them transfered to ICU ASAP. It will take time to gain experience but you also have to empower yourself to learn more about what you don't know.

[traumalover, RN]

everytime I've received an order for a gtt it states start levo gtt and titrate for sbp>90 or map>60. They've also said occasionally start at a certain rate but never titrate by so much, only titrate for desired effect. Could you possibly shadow in ICU for a few shifts and spend some time titrating vasoactive gtts with an experienced ICU nurse?

[emtb2rn, BSN, RN, EMT-B]

Anyone who thinks "a nurse is a nurse is a nurse" doesn't realize how much more some doctors expect out of critical care nurses.

I'm very familiar (and comfortable) with the emergent "titrate to life" order. I was responding to that poster stating about "never" getting parameters.

[Anna Flaxis, BSN, RN]

You need to have some sort of pocket reference, whether it is a smart phone with Epocrates, Medscape, and whatever other references you like, or an actual physical pocket guide.

I like the Medscape drug reference because it has administration instructions, unlike Epocrates. I also have a copy of "2014 Intravenous Medications" on my Kindle, which I can access from my Android phone- yes, it's a little more time consuming but it has all the info I need. A couple of my coworkers carry little paperback pocket guides that have come in handy on several occasions.

Does your workplace not provide a reference such as Micromedex on the computer work stations? Do you not have drip protocols online?

The point is, you should have the ability to look things up when you don't know them, whether it's drugs, procedures, protocols, or whatever. It's great that they provide you with a drip book, but when it's not where it's supposed to be, doesn't contain everything in the formulary, or hasn't been updated in a while, this can be problematic. This is why I like to have my own resources that I am familiar with. Also, when there is down time (I know, "Down time- what is that?"...but seriously) this is a good time to do things like track down that drip book and make sure it's where it's supposed to be, check the computer network to learn how to navigate to Micromedex, protocols, P&P quickly- in other words, think about "what ifs" and reheorifice where you would go to look up your various drips and such.

And I agree, don't do anything without a written order. I know it's tempting to just implement a verbal order in the interest of expediency, but it's true you will get thrown under the bus if something goes sideways.

I had a physician tell me verbally that he wanted to give a medication intravenously. I went into the room and attempted the IV start, unsuccessfully. When I came out and reported this, he said "Oh, I didn't order an IV, I was going to order it PO". No, I distinctly heard IV- I am 100% sure of it. But he denied ever saying IV. So I had attempted an IV start without ever having an order because I distinctly heard the physician say IV, and now he was denying it. This is relatively minor compared to what could have happened, but it was a really good lesson to me to wait until I get the written order. I had previously been really comfortable with verbal orders because no physician had ever done this, and had without fail always followed up with a written order- but it only takes once and you're screwed.

[Anna Flaxis, BSN, RN]

if you don't have parameters, then aren't you practicing medicine without a license?

Not if your facility has a protocol for that drip. Then the physician can write for the med "per protocol", and you just follow that. Kinda hard to do though if you can't find the darn drip book! My facility's protocols are online- we don't have a book. So what we will do is find the protocol and print it out and have it handy at the bedside.

[NurseOnAMotorcycle, ASN, RN]

... Patients super unstable should be 1:1 or 1:2 (as in two nurses), regardless of location...

Ah ha ha ha haa!!!

Everyone here knows that what should be isn't what actually is. I've had plenty of days where I've had three of these kinds of patients and 3 nonacute hallway beds at the same time.

I completely agree with you about "get them to the unit as soon as possible" because their staffing and patient loads actually allow for that.

Fencer1119, I have to say that for someone with only a year under your belt, you did great. You weren't stupid enough to just try to figure it out on your own, you called every resource you had available, and you used good clinical judgement in that you thought about the pt's comorbidities and their effects on the pt.

Seriously, BRAVO!! I wholeheartedly commend you for looking up all of your answers afterwards instead of saying "Thank God that's over!" and forgetting all about it. The only way to be the experienced emergency nurse is to do it and get that experience. You are well on your way, as scary and tenuous as it feels right now. I bet that you'll never let the provider get away with "start it at whatever the book says" ever again.

[PMFB-RN, RN]

Why on earth was the charge nurse dictating where to start a med and how to titrate? That should have been in the orders or at least verbilized by the ED attending!!!! Yes, I get that it was a crazy night, BTDT, but ANY vasoactive drug should have clear orders from the PHYSICIAN.

I have never worked anywhere where a doctor would tell nurses where to start and how/when to titrate drips.

Our orders are drug and what the goal is. For example "Norepinephrin gtt to keep SBP >90". I very much doubt most of our docs have any idea what the starting rate of a drip is or how to titrate it. Starting doses, max doses, and how to titrate are all in unit protocols and subject to nurses discretion.

[PMFB-RN, RN]

To the OP. You were thrown to the wolves by your employer and not provided adequate training by your hospital. We would never graduate one of our nurse residents without them being comfortable with the patient population, drugs and procedures normal in that unit.