Feel like I'm too dumb to be a nurse

[coconut3431]

I've been working as a nurse for 4 months. Today, i had a resident's family member come in and say that she (resident ) doesn't look right. The family member said they told the other nurse that she is getting worst and worst. Now, this is the first time I had this patient. So, I take her vital signs everything is normal. Her o2 was 92. I even get an rn to come and recheck her to make sure. The rn rechecks her and says nothing seems out of the ordinary but that she'll call the doctor to order blood test to make sure. So I call the doctor. The doctor tells me to get a chest xray and blood work. So i get the chest xray done, and send off for bloodwork. Chest x ray reveal pneumonia. I thought the chest xray was sent to her office. So I wait on the doctors call, meanwhile i finish passing out my meds. She calls at 5 pm and says its 5pm why haven't I call her? I tell her my reason and aplogize, she says I need to take better care of my patient. I have people lives in my hand. During my shift i an taking the residents vital signs they are normal. Towards the end of shift change i tell the nurse taking over what's going on with the patient. She goes a takes her vital signs and they are really low. They send her out and call the doctor . The doctor tells her she should be reported, and that this is unacceptable. The nurse says you right she could've died. I can hear the cna's saying she's a nurse, you think she would know. Im sitting there looking stupid. I feel like I'm too dumb to be a nurse. Does anyone have any advice, became i am thinking of quitting my job.

[Ruby Vee, BSN]

I'm not sure why you're thinking of quitting your job. Did you think that you would come into nursing automatically knowing everything you need to know to safely care for your patients? It takes experience to pull it all together, and that takes about two years. You will make mistakes, errors in judgement and outright "OOPs"s. Everyone does. "Being a nurse" doesn't mean you suddenly know it all.

What did you learn from this?

If the family sees a change in the resident, investigate. You did that one right, even getting someone else to look things over and give you advice and a second opinion.

You learned that if the chest X-ray shows something abnormal, changed or unexpected you need to communicate with the physician. If, after half an hour or four hours (my background is ICU so your timeframe may be somewhat different -- go by the timeframe appropriate to your setting) you haven't heard from the physician, call them back. "Radiology says Mrs. Pulm's X-ray looks like pneumonia -- have you had a chance to look at it?" Physicians get busy and forget to check back. As your patient's advocate, you can't let them forget your patient.

If there's a change in your patient or some reason to think there may be a change (that X-ray? the family's observations?) take vital signs more frequently. It is better to catch that blood pressure on the way down or that heart rate on the way up than it is to catch it four hours later when suddenly everything catches up with the patient and she can no longer compensate. It's entirely possible that you DID take the vital signs more frequently and you just happened to get her last "fine" set of signs and the other nurse just happened to walk in when she had decompensated. It happens. It happens to even fine, experienced nurses. It can certainly happen to a new grad who hasn't yet learned to pull it all together. The doctor may have been kicking herself for not paying more attention and lashed out at the nursing staff, too. That happens. It's not desirable, but it's not the end of the world, either.

No one walks into nursing completely competent. Competent nurses still miss things. So do competent physicians. I once had a patient complaining vaguely of "chest feels funny", nausea and fatigue. Some little voice told me to do a 12 lead ECG, which I did. It showed minor S-T changes, barely making the criteria for change. Some nagging little voice told me to show it to the cardiologist, so I found him where he was making rounds in the MICU and showed it to him. He dismissed it as "no big deal." But that little voice kept nagging at me, and persisted in asking him "so these small changes here and here aren't a big deal, even given the symptoms he's describing?" Something in my voice or my delivery must have gotten the cardiologist's little voice going, because he walked over to the CCU with me. We did another ECG, and this one was quite clearly abnormal. We got him to the cath lab for an intervention just in time. If I hadn't been persistent, we would have missed the ECG changes until that patient was in real trouble.

It's very easy for the CNAs to sit at the nurse's station, and with their 20/20 hindsight conclude that "the nurse should have known." Nursing is a team effort. If they had concerns, it was their obligation to voice them at the time, not engage in Monday morning quarterbacking.

You had a patient develop pneumonia and decompensate on you. Hopefully, you went home and read up about pneumonia and how it presents in the elderly, what to watch out for and what should be done. And you learned, didn't you? Next time, you'll have a better idea of how to deal. That's what being a good nurse is all about. Learning from mistakes, from near misses, from what could have happened. You never quit learning.

[TheCommuter, BSN, RN]

I do not feel like you should leave nursing, nor do I feel you are dumb. On the other hand, you would definitely benefit from more training.

I assume you work in the LTC/SNF/nursing home setting. In most cases, results for labs and imaging (e.g. x-rays, ultrasounds) are usually NOT transmitted to the resident's doctor. Therefore, it will be up to you to fax normal results to the doctor's office and/or immediately telephone the physician with abnormal results. It is your job to make the doctor aware of lab/x-ray results.

Also, an 02 saturation of 92% is not normal unless the resident has a history of COPD and a tendency to retain C02. For those without COPD, we prefer the 02 saturation to be in the mid 90s or more.

And as always, assess your resident, not the machinery. The vital signs and machine readings might be indicative of a stable patient, but you will need to intervene if he/she just does not look right.

Good luck to you.

[AliNajaCat]

It's a common (though sometimes dangerous) to think that SpO2 (percentage of red cells saturated with oxygen, normal 95-100 on room air) is the same as PaO2 (pressure of oxygen in arterial blood, normal 80-100 on room air). It is really, really not. While a PaO2 of 92 on room air is just fine, a SpO2 of 92 is definitely concerning if a new finding, as with your patient.

So you learned something today. You should be learning at least 1-2 new things a week at this point.

[coconut3431]

Did you ever make a huge mistake in your years as a nurse?

[MunoRN, RN]

I have to disagree that you made some sort of "huge mistake". The O2 sat, if it was significantly below her normal indicated the need for a CXR, which was done. I've never encountered an LTC protocol where a doctor who ordered a CXR can only find out the result by the LTC calling them. The MD ordered the CXR, they are responsible for following up on the result.

[CaffeinePOQ4HPRN, BSN, MSN, LPN, RN]

...Did you think that you would come into nursing automatically knowing everything you need to know to safely care for your patients?

I'm reiterating this part of the poster's quote out of kindness. You know, we have all had feelings of inadequacy... TRUST ME! I delayed becoming a nurse because (for a while) I believed the abusive language of others telling me I was "too stupid" etc. I did a 4-year undergrad and 2-year masters, before I believed enough in myself that I was smart enough and good enough to be a nurse. It's likely that you're in the wrong environment or don't have adequate practice supports to help you feel comfortable. Not all of us nurses are built tough enough to hit the ground running fiercely, the kindest nurses oftentimes need extra support while they're acclimatizing to their newfound autonomy. It comes with time and experience... feeling comfortable and confident, that is. Be kind to yourself... a nursing career is an ever-evolving learning process..

On a side note, please remember that apart from vital signs... if a patient or someone who knows them well expresses concern that they're not their usual self or suspicions/worry of change in health status, always do a full head-to-toe assessment...including auscultation of your patient's heart/lungs. That could've helped to reveal rales/crackles which would've triggered a red flag for potential diagnosis/risk of pneumonia and other complications. BP, O2Sats, and temp alone are not sufficient per pt assessment if a change in their health status is suspected.

From what I gather you weren't negligent. You did the best you could to take care of this patient and you have now learned some things to help you improve future patient encounters. You communicated with your team, had the MD order appropriate diagnostics... please don't worry about this anymore than you already have. Keep in mind, most healthcare practitioners are naturally impatient and they want an instant solution as of yesterday and if you can't be perfect they try to psychologically dismantle you... don't pay them any mind, just use it as an opportunity to improve your knowledge and defenses. After time you get used to it and you don't take it personally and know how to handle them when they're

[Wolf at the Door, BSN]

The MD should have access to ALL EHR outside the facility. MDs can view all blood work and images. Why did the MD wait until many hours to contact you? MD has more than one patient but, so do you. Learning exp move on...we can't catch everything..People inflict damage to themselves that is often irreversible, we just manage the symptoms we can't cure.

[coconut3431]

The reason why if feel responsible and mad at myself is because the doctor ordered xray around 3:45. I thought they altimatically send it to the doctor. Doctor calls me back its 2 and 3 hours later. If I knew that I had to call the doctor bck I would have. I really didn't know. I kept checking on the patient and didn't take her vitals in the last hour. That's when her vital signs went down. Any way they sent her out come to find out she was septic and now in icu.

[jaycam, RN]

Learn and let it go.

Western culture puts so much emphasis on success, that we start to see every failure as catastrophic. It's not. Your patient had to be sent out, but it's not the end of their world, much less yours. If you continue to "what if" the situation, you're only going to hurt yourself more. The true failure is when we don't learn from our mistakes. I was a med tech/nursing assistant for many years before going back to school for nursing. One thing I found out really quickly is that my nurses tended to prefer techs who had made a med error in the past. Preferably not a serious one based in negligence, but enough preferred it that it had made me curious. The explanation I got when I asked was "Someone who has made a nonserious mistake and learned from it is less likely to repeat that mistake, but someone who says they have never made a mistake is likely lying to you." You seem to have learned several lessons from this, plus you did several things well, like listening to the family and pushing even after the RN agreed with your initial assessment as being within normal limits. I'm a new grad myself, and I know I'm not perfect. I will never be perfect, but I will always try to improve.

[Libby1987]

I'm in home health and our responsibility to report abnormal test results, despite the results being available and/or sent to the provider, is something very counter intuitive to our new hires. The fact that the provider can and/or should track what they order doesn't absolve us of our responsibility. Clearly it can prevent patients from falling through the cracks, which is too common. Lesson learned, you are not alone in your initial understanding.

What I advise my new staff, particularly newer nurses, is to 1) learn what is abnormal 2) know or investigate your patient's baseline 3) be conservative and report anything outside of normal until you develop a better idea of what needs to be reported immediately, what can be reported when it's convenient and what needs to be watched until there's a pattern or increase. Up until then you will need to over report.

That can be discouraging when a provider or their representative make you feel like you've over reacted but I've found that if I say upfront that I'm not sure if my call is warranted so I rather err on the side of over reacting I will receive a softer reaction by providers, in my experience. They often will give an explanation, I assume because I've admitted that I wasn't sure if it was significant. It has helped me grow my nursing judgment.

Don't let a lesson make you quit, make the most of it and grow.

[TheCommuter, BSN, RN]

The MD should have access to ALL EHR outside the facility.

The OP works at a nursing home/LTC/SNF. Not all nursing homes have converted to EHR systems due to the time and massive expense involved. Hence, it is very possible that the OP works at a facility that still utilizes old-fashioned paper charting.