first day off orientation should i feel bad about this

[barlowjb]

Hi guys, I apologize for this long post but I really need some advice. yesterday (3pm - 11:30pm) was my first time off orientation as a new nurse. I was not nervous, but was curious to see how well I would do as far as time management was concerned. I had 5 patients and I prioritized and saw my most unstable patient first (Patient 1) and spent quite a bit of time with him throughout the evening because he needed total assist and was having other issues.

I went on down the line introducing myself to all my patients, making sure all were ok on pain control. One of these pts was a new admit (Patient 5), so I tended to him and checked off his meds etc and was later in the process of giving him his meds.

I was about to leave Pt 5 to go see another Pt (Pt 4) - by this time It was almost 10pm and I had completed all my assessments, given most of my meds and had done most of my documentations. The only thing I had left to do was give 10 pm medications to pt 4, and complete documentation of her assessment, but alas the unpredictable happened:

An aide came to me and told me that Pt 3 had a very low BP (80s/50s) but that she was conversant, was not dizzy and said she felt fine. I was about to go see Pt 3 for myself when I noticed that Pt 2's call light was on. In my opinion of all the pts Pt 2 (about 70-80 years old) was the most stable and I had seen her earlier that evening. However, I'm not sure why but it bugged me that her light was on (one of my pet peeves), plus she had not complained or asked for anything all evening, so I was curious. So although I was en route to see Pt 3, I went to see if Pt 2 was ok or if an aide was with her.

I walked into the room of Pt 2 only to have her tell me she was having chest pain of 8/10 and it had radiated to her right jaw and that she wanted a drink of water because that had helped her in the past. The first thing I did (before fumbling to see which Doctor I should call - since I am still new at this) was immediately inform the charge nurse (she was close by) who quickly rounded up another nurse for help. One nurse called the Dr. My charge nurse continued to assess the pt while I kept the time on all that was going on and charted. Per the MD's order, I administered 1 mg morphine. As it turned out the pt stopped having chest pains. Later the results of the EKG came back (abnormal) and I notified the MD who came to the floor to check on the pt.

At the time the crisis was resolving the aide returned to me and asked if I wanted him to recheck Pt 3's BP to see if it was still low, Well here is the thing, I told him yes. My reason for telling him yes was because I was still finishing up some work related to the crisis for Pt 2. Anyway I felt stupid because the charge nurse immediately asked me if I had seen that pt since the report of the Low BP, I told her no and tried to explain that I practically had two crises (1 actual and one potential) at the same time. She told me that I needed to see the pt first and to not just tell the aid to go check it again. Anyway, I checked , it was still low, I called the doctor and he told me to just continue to monitor the pt (she had been low before my shift started) and she was still doing ok.

Should I feel bad about neglecting to check on pt 3 considering the circumstances. What could I have done differently?

Another thing is that as I mentioned, throughout the shift I spent a lot of time (with help from a CNA) with Pt 1. Well it turns out that the wife of pt 1 asked told me that she could not find his lens. Call me stupid but it did not dawn on me that she was talking about eye glasses, I thought she meant contact lens and I never pursued the issue because honestly based on everything else that was going on I didn't even think about it. Plus I thought she meant that they lost it themselves (not the hospital).

Now I'm on my day off and got a call from the charge nurse asking me if I knew anything about the pt's eye glass. I told her that the pt's wife had mentioned it and she said that I should have pursued the matter, that they have to write up an incident report and that the hospital may have to pay for the pt's property. Coupled with that the pt's dentures were also missing - they were taken out and placed in a cup, covered by a paper towel right before the pt was sent off the unit for a procedure (which by the way was hours before the start of my shift), so they were asking me if I knew anything about the pt's dentures, because now the hospital may have to pay for that too. I acknowledge that I should have pursued the lens issue further, but I swear I knew nothing about the teeth and I did not throw anything out.

Anyway putting aside the issue of the pt's property, I had managed to complete most of my documentations after each pt assessment, and pts had their medications in relatively good time. I ended up being about 1 hour late with medications for one patient due to the crisis and ended up doing a little over one hour overtime in order to give report and complete one set of documentation.

I didn't get any bad feelings from the other nurses and I think they were pretty supportive from start to finish, I did not bug them a whole lot, except for the crisis, but sometimes I just wonder because you never know how people truly feel sometimes. To be quite honest I don't feel I did badly for my first "independent day" and I'm usually extremely hard on myself.

In any case, my main question is considering the fact that this was my first day off orientation, how do you guys think I did overall and what do you think about the entire evening because now I find myself thinking about what I could have done etc, and the more I think about it the worse I feel and to be honest I have thought myself right into a depression and am anxious about what they are going to say to me about the pt's missing dentures and lens tomorrow.

[classicdame, MSN, EdD]

yes, you should feel bad. That way your stress level will rise, you will feel incompetent and unable to get any work done then wonder why you are a nurse.

OF COURSE NOT. Consider it a learning experience. And remember you are not alone - ask for help when needed. Rather than ask for the aide to assess, consider having the aide STAY in the room till a nurse arrives (you or someone else). That way someone can call a code if needed.

[barlowjb]

Thanks for the advice, I will bear that in mind if I ever have two crises at the same time.

My first three days so far have been ok and I am learning more and more each day. Turns out I am way more stressed than I should be. To be honest, I have really good resources around, I have been getting positive feedback from the nurses around me and one nurse actually told me that it will take a good 2 years for me to really get a lot of things as she puts it.

My main goal right now is to never put any patient in danger in the process of gaining more experience.

So thanks again for your honest feedback

[MNRN2009]

Do you have an assigned resource nurse? My first 2 weeks off orientation I had another RN that was assigned as my resource. Of course all the nurses were available to help me if needed, but it was nice to know that I had a go-to person. No, you did nothing wrong. Chest pain over rules most things. BP of 80/50 is low and needs to be addressed, but pt was A&Ox3. I had someone with BP of 66/37 not too long ago and all the MD ordered was a fluid bolus that brought him up to 95/50 which was acceptable for this particular patient. This pt was also A&Ox3. As far as feeling bad, you will feel that way after almost every shift for awhile. That doesn't mean you did anything wrong, just that you are concerned and that's a good thing.

[barlowjb]

No, I don't have an assigned resource nurse, but my 8 week orientation (on three different floors - i.e. a surgical cluster) was set up to where I had a main preceptor (in addition to 7 or 8 others), but all the other nurses were encouraged to sort of nurture me whenever they had a chance. I interacted with all the nurses and let them know which experiences I would like to get more of. So I was always asked if I wanted to try this or that.

Well that trend so far has continued after my orientation was over, so I feel comfortable asking 99% of the other nurses for advice. The other nurses have truly been helpful in making me feel comfortable.

I must point out that there is one other new grad in the surgical cluster and she appears to get the same treatment that I do.

I still have a lot of questions, but for the most part unless its quite pressing, I make note of what I want to ask and try to find the right time (when the other nurses have some down time) to ask my questions.

[canoehead, BSN, RN]

What you did made sense to me. I also would have said yes to the aide rechecking the BP, with the plan that I would follow them within 5 min or so for a more thorough assessment.

[NJNursing, ASN, RN]

Stop beating yourself up over it. It was your FIRST night off orientation. You're still getting the time mgmt thing handled. I, personally, think what you did was appropriate. I probably would of had someone retake that blood pressure - manually and in both arms before I called it a gospel number and I would of asked the aid to do that while i was in with the lady with the chest pain. Had you gone to see the low BP, the lady with the chest pain could of ended up with a major MI had you not intervened so soon. The low BP is also a concern and in the scale of ABC's both were C's, but 80's over 50's and non-symptomatic, I also would of let go a little bit. I would of quickly encouraged PO fluids while walking to the call light. After the repeated signs I probably would of asked another nurse to handle that pt while the other crisis was going on. You're talking stable vs. unstable pt and you did the right thing.

The issue about the glasses - that's just a learning experience. You can pretty much guess that pt's past the age of 60 aren't wearing contacts, most of the time. Yeah, the hospital hates to have to fork out for anything they don't have to, especially glasses and dentures which will probably cost them $1,000. It happens, though and it could of been lost anywhere along the course of their stay, and not necessarily just on your shift. If there was an aid in there an the wife brought it to their attention, they could of looked for the lens just as much as you could of. Don't beat yourself up. Learn from it and move on. Tomorrow, after all, is another day!

[leslie :-D]

i think it sounds like you did an excellent job, considering it was your 1st noc off orientation.

you clearly knew who your priorities were, and sounds like you were on the ball.

as for the bp, yes, the aide could have done, as long as you followed up with the pt.

minor mistakes...

heck, we'll call them 'glitches'.

keep it going.:balloons:

leslie

[barlowjb]

Thank you all for your advice which helped me emotionally at the time. Its been many weeks now and I have learned not to beat upon myself for every little thing. Concerning patients belongings such as dentures etc. I have started putting stuff like dentures or hearing aids in clear specimen cups that can be seen, or in clear plastic bags with labels. Nobody said anything to me about the patient's belongings when I went back to work, so I just let it rest. So far I am fulfilled by what I am doing and am looking forward to learning a lot more.

[vanlo001]

Good job barlowjb. The mere fact you are reexaminig the whole night speaks volumes in regards to your ability to self reflect and analyze how you can do better. It will get easier with each night, each experience, and each crisis. Keep up the good work.

[corky1272RN]

Next time try to call the charge nurse to assist with the other pt. To me know matter how many years of experience a nurse has, a careless nurse is one who can't ask questions or for help when she needs it.

At my hospital, there are several nurses that take turns working as charge. Two nights ago I noticed that one of the nurses who also works as charge nurse sometimes was asking the current charge nurse to come look at a PICC line (it just didn't look right to her). Made me feel a little better because I thought "man if she feels like she can ask for another's opinion/help then I surely can".