Am I overreacting?

macawake, MSN · Oct 8, 2018

Butterfingers :facepalm: :x3:

Double post :)

marable · Oct 8, 2018

The hospital where I worked had protocols that were used as an order sheet for a patient on an epidural drip , signed by the doctor with any changes that he wanted....When I precepted new nurses my patients were still my responsibility...When I had patients returned from surgery/pacu I assessed my post op patients ...Instructed the new nurse to assess the patient and chart her findings , then , I reviewed what she had charted and signed behind her and possibly made my own note entry if she did not address it...As a nurse there will always be things that present themselves that you are not familiar with ....Follow your hospital protocol ...Ask for help from more experienced nurses ...If the nurses on the unit with you don't have experience then call another unit and ask for help...

Rainbow_RN, BSN, RN · Oct 9, 2018

Fellow new grad here. I would feel uncomfortable with it, but I also wouldn't turn it down as an unsafe assignment. I would ask around on my floor, which it sounds like you did. Then, I would go look at the policies and procedures of my facility. If I am still unsure, and I have reason to believe the patient is going to experience a complication or i have orders to do something with the epid, I would call the surgeon or call anesthesia. For the most part, it seems like it would just be monitoring. I wouldn't imagine they'd ask you to put any medications through it yourself, and definitely not to remove it yourself. Common sense would dictate that it involves frequent neuro checks. It would be nice if every nurse went through a class about epidurals, but I've only ever seen them in OB areas.

LovingLife123 · Oct 9, 2018

I'm a Scandinavian nurse and what you describe would actually be considered problematic here. In order for a nurse to care for patients with either an epidural or intrathecal cathether they would have to attend a one-day class. That usually happens during orientation if your first job is in a hospital. A couple of times I've seen messages on my hospital's intranet that a certain floor won't take patients with epidurals because not enough nurses on the shift are certified. It doesn't happen often, but I've seen it a few times over the years.
Even as a recently graduated nurse you're of course expected to know aseptic technique but the class covers things like the checks you need to do apart from pain assessment and vitals, which you check for all opioid administration. Things like how to assess motor block/bromage scale, which dermatomes are are affected, urinary retention etc. Of course you also need to be aware of the signs of the possible, rare but serious, complications like for example subdural hematomas, abscesses and meningitis. When removing a epidural catheter it's important to know the patient's coagulation status and what checks need to be made after the removal.
What I've written doesn't cover everything there is to know about epidural analgesia and isn't intended as a guideline/advice. I only wrote this to illustrate why I think it's important that a nurse receives training in caring for patient's with epidurals. I work and practice in a different country and what's standard practice here might not be the same in the U.S.
OP, I echo the advice from other posters. Hopefully you have access to a clinical nurse educator who can help you gain proficiency.
I don't know if I'm interpreteing responses correctly here? It seems that other posters aren't very surprised or bothered by the fact that the other nurses on your floor don't seem have much experience with epidural analgesia either. I don't know if that's normal? Personally I find that less than ideal if it's a pain treatment method that's commonly used for your patient population.

Epidurals are a pretty common occurrence at least in my facility. There should be a hospital policy on them and they really aren't that difficult to manage.

I feel if you are doing your assessments properly it shouldn't be a big deal. There are plenty of things I did not get in orientation many moons ago. I still come across things I haven't seen before. I ask my fellow nurses and use my resources to educate myself.

If I refused every assignment because I had never had it before, I would never learn and grow.

It kills me when we get nurses that say, oh, I don't do CRRT halfway through report then we have to switch assignments and give report again. How will you ever be competent and learn if you don't actually experience it?

I feel like some people will give any excuse they can to refuse an assignment. Epidurals are not difficult. Doing proper neuro assessments, and site assessments, and pain assessments, however your policy dictates should suffice. I know ours are more frequent at the beginning of an epidural placement. Also making sure you have an extra cassette on hand is a must.

Triddin · Oct 9, 2018

Epidurals are a pretty common occurrence at least in my facility. There should be a hospital policy on them and they really aren't that difficult to manage.
I feel if you are doing your assessments properly it shouldn't be a big deal. There are plenty of things I did not get in orientation many moons ago. I still come across things I haven't seen before. I ask my fellow nurses and use my resources to educate myself.
If I refused every assignment because I had never had it before, I would never learn and grow.
It kills me when we get nurses that say, oh, I don't do CRRT halfway through report then we have to switch assignments and give report again. How will you ever be competent and learn if you don't actually experience it?
I feel like some people will give any excuse they can to refuse an assignment. Epidurals are not difficult. Doing proper neuro assessments, and site assessments, and pain assessments, however your policy dictates should suffice. I know ours are more frequent at the beginning of an epidural placement. Also making sure you have an extra cassette on hand is a must.

I get changing the assignment for non CRRT trained nurses. We have to do an extra days worth of classes to take a CRRT assignment. CRRT is far more involved than monitoring an epidural with a greater chance of killing someone. So I would not take a CRRT patient without that training or being cleared by the education team.

I think I only saw 2 epidurals in my time in surgical. They weren't common on our wards so I can understand the nurses on the floor not being 100% comfortable with them. Our surgeons/ anesthesia team seemed to prefer PCAs, at least when I was on.

AGRN152 · Oct 9, 2018

I will agree with most of the posts here and say that comfort comes from experience but you will always have a Day 1. Orientation, regardless of how big the unit or how expansive the amount of time spent orienting, will never cover every single type of patient multiple times in order to afford comfort in caring for the patient. I always ask the nurse giving me report what to look out for or what my areas of concern would be if I am uncertain as to what we are looking out for. If the preceding shift is also unsure, there is always a senior nurse on the floor and if everyone is a 1-2 year nurse (sometimes a common finding on night shift), then there is always a resident or a physician who can explain what they want done and what their areas of concern are. Nursing is a profession built on experience, asking questions, and humility. An epidural is a great experience to seek out and can help you build on your experience especially if you end up caring for patients with nerve blocks or other forms of regional analgesia.

Kallie3006, ADN · Oct 9, 2018

I understand the concern of having a patient with an epidural without having encountered that before. I also find it a tad concerning that the floor doesn't seem to have much experience with them and they give the patient to a new grad. (not that you are not capable of providing safe care for the patient). If you are getting report as change of shift then I would have the nurse handing off the patient tell you what the expectations of the care are for you, what you need to look for and be aware of. If this is a new admit from the PACU I would ask that nurse. Also when you get something you are not familiar with, I would suggest going into the room and assessing that area with the nurse giving you report. This will allow you a baseline on what the site looks like, how the catheter is secured, what the infusion rate is set and what is infusing in it. This will also give you guidance throughout your shift when you are checking the site since you will know what it is supposed to look like and will be alert to any changes. If your unit doesn't take patients with epidurals I would find out the unit they usually go to and call and ask them what you need to do, look out for etc. if your resources on your unit are not able to assist you with those questions.

congrats on passing boards and getting through orientation!! Welcome to nursing!

osceteacher · Oct 9, 2018

Sorry but its a no from me. You're not over reacting, you should not be given a patient with a device that you're not trained in. I'm a medical device trainer in my other role and our policy is very clear, particularly regarding a high risk device like an epidural. You get trained in this device then you can potentially look after a patient with one in use. This is in line with national medical device guidelines.

I completely disagree that the best way to get used to a high risk medical device is just to get exposed to it. Complacency around these devices is common, particularly with those who use them regularly. We have had SIX incidents this year alone regarding epidurals and their misuse. Attend a formal training on the device first, then use it.

If you haven;t encountered something DO NOT just wade in and carry on, the number of incidents I have to investigate because of this is pretty astronomical.

We'd have a field day with the unit you work in.

macawake, MSN · Oct 9, 2018

Epidurals are a pretty common occurrence at least in my facility. There should be a hospital policy on them and they really aren't that difficult to manage.

Epidurals are not difficult.

I'm not sure if you're addressing OP or me but since you quoted my post, I'll reply.

Here are my $0.02... for whatever they're worth :)

They are pretty common in my facility too and since I've specialized in anesthesia and used to be a PACU nurse prior to that, I don't think they are all that "difficult" either. However, while I don't think that they are difficult, I still after eleven years of doing this, maintain the utmost respect for stuff that we stick into and inject into a human being's epidural space or spinal canal.

OP is a new grad though and doesn't have any experience with epidural analgesia and from what I understand s/he does not seem to have coworkers on the same floor who can serve as support. To me that sounds far from ideal.

If I refused every assignment because I had never had it before, I would never learn and grow.

How will you ever be competent and learn if you don't actually experience it?

Personally I think that the right way to become proficient is to first learn how the device/pump you're using works and become familiar with the medications used, which safety checks that need to be done and the possible complications that can occur and what the early signs are, then you start practising on your guinea pigs. Oops, patients. Learning on the fly in an environment where no one seems to have any real expertise isn't something I would want for myself and I certainly wouldn't want to be the patient in that scenario.

There are plenty of things I did not get in orientation many moons ago. I still come across things I haven't seen before. I ask my fellow nurses and use my resources to educate myself.

Again, that seems to be part of the problem here. Does it sound like OP has nurses close by who are experienced in the management of epidural analgesia which s/he can "lean on" for support?

We've all been new grads at some point. One of the hardest things for many/most new grads is time management. You're usually plenty busy just trying to juggle your entire patient load without the added stress of not having received proper training in how to use the devices that your patients are hooked up to. It's my personal opinion that it's the employer's responsibility to ensure that their staff receive proper training. That's in my opinion a necessary component of a strong safety culture.

We've long had a tradition in medicine and nursing of "see one, do one, teach one", but from a patient safety perspective I personally feel that more in-depth training is often a sound and desirable strategy.

So I would not take a CRRT patient without that training or being cleared by the education team.

I agree. To me, it's the responsible choice.

Our surgeons/ anesthesia team seemed to prefer PCAs, at least when I was on.

I like both IV-PCA and PCEA and I expect that the floor nurses that care for postoperative patients are trained/proficient in handling them.

Sorry but its a no from me. You're not over reacting, you should not be given a patient with a device that you're not trained in.

You get trained in this device then you can potentially look after a patient with one in use. This is in line with national medical device guidelines.

I agree 100%. To me that's just common sense.

As I mentioned in my previous post, floors in my hospital won't take patients with epidurals unless the nurses on duty have undergone training in handling them. I noticed that you're from the UK so you probably know, but American nurses might not, that practising in my country is different from the U.S. Here, nurses and physicians don't have malpractice / insurance. We don't get sued. The policy to train nurses in epidural analgesia isn't motivated by fear, but the decision to provide the training is based on the belief that the training is valuable/necessary.

I completely disagree that the best way to get used to a high risk medical device is just to get exposed to it. Complacency around these devices is common, particularly with those who use them regularly.

Again, I completely agree.

Workitinurfava, BSN, RN · Oct 9, 2018

Just tell them you are not comfortable so you can get help.

Pediatric Critical Care Columnist · Oct 9, 2018

My unit provides "training" on a multitude of devices. And once you've signed the sheet the trainer passes around at the beginning of the "training" you're considered competent and would be excoriated to the bone for suggesting you're not capable of caring for a patient with that device. The reason why I've put "training" in quotes is that on my unit it is defined as either having read through a PowerPoint (how I was "trained" to use our new defibrillator) or having been provided a 10 minute run-through with the manufacturer's rep (which is how I was "trained" on our new PCA pumps). I'm CRRT-trained, which comes in handy on that one day a year when I'm the only one on the schedule with a check-mark next to my name and we've got a patient who's clotting a filter - or two - or three - a shift. I have check-marks for lots of things I've never had any hands-on practice with, and when I suggest the methods used for training us aren't effective, I get The Stare.

Jvn11 · Oct 10, 2018

I obviously asked for help people and never refused the patient. I was posting this right after my shift kind of in the heat of the moment. It was just frustrating because our floor does not get epidurals and I really had no one to lean on for support. It is interesting to see everyone's opinions about this. I am not sure why some people on here reply kind of rude. Thought we were here to support each other !