Feel like a horrible nurse!

[Verygreennurse]

Last nights shift made me feel like i never even even to nursing school!

I have a pt with esrd and heading for dialysis at 0800. He has many serious problems but this is what i am focusing on. His bp rises around 0445 to 166/89. I next check it around 0545 and its 168/98. I get hung up on a note in the system saying notify physician is systolic is >200 or diastolic is > 100. I decided to call at this point figuring it was close enough and im becoming really nervous about it. I bring up the nephrologist note again and realize is says diastolic > 115! I started talking it over with another nurse and we are pulled away. By this time its around 0720 and the np is 170/101. The attending is there; i showed him the note that i saw and that the pt was going to dialysis and i was concerned with bottoming him out. He said i should have called when his diastolic was >90. He put in prn meds and added another bp med. He was really nice, took time to talk to me about it

The note was by the nephrologist. Not the attending.

I still feel crappy. 1) should have went with my gut i thought the note was ridiculous. I was suppose wait till he was in crisis mode to call?! 2) i should have talked to my coworkers about it more to make a better decision about that note 3) should have went to my charge 4) i know better!!!

Its my 6th shift after orientation which was 6 weeks. My first nursing job! I work on a tele/stroke unit.and i love it! Just feel so inadequate. Feel like i miss a lot. I knew i would feel this way just starting out and some days are just harder than others. I feel like i am getting more organized and finding my groove, then this happens amd i feel lile a horrible nurse. Ill of course harp on the mistske from last night and forget about all the good i did.

Nursing is hard.

[Tenebrae, BSN, RN]

Ummmm, if the order said call when >115 why would you call when it's >90?

Yup

You aren't a mind reader, if the doc wanted you to call when the systolic was >90 he should have put the order in

Stop beating yourself up for not being perfect. It sounds like you handled it the best it could have been handled

[Mavrick, BSN, RN]

I expected to read something " horrible" from your title and I didn't. It's hard when you are new and don't know what to worry about and what not to worry about. A lot of dialysis patient's blood pressure will trend up close to their dialysis appointment and be significantly lower after. The nephrologist is probably comfortable letting it run higher than a primary knowing he was going to have a treatment soon and from past history.

You did fine. Don't beat your self up over this.

Primary attending docs don't know everything, that's why they call in specialty consultants. Nephrologists know what is acceptable for their patient population. You did nothing wrong. I'm guessing Primary was thinking about what a cardiologist thinks is too high a diastolic pressure. You did nothing wrong.

Actually your critical thinking was working pretty well to anticipate the diastolic might be rising and to recheck a B/P. Nothing wrong with a nursing consult either.

Stay frosty and learn from these experiences. That's how you get to be the experienced nurse that others come to for a nursing consult!

[DTWriter]

Welcome to nursing!

For the first year (especially), expect to make mistakes. Smart colleagues (other nurses, physicians, NPs, techs, etc.) will expect it and understand (though, try not to make the habit of making the same mistakes over and over again). (Though, based on your post, you followed orders... Meh. Now, you know to call when in doubt.)

OP, it seems you have a supportive environment. Keep going~

[Medic/Nurse, BSN, RN]

JTelepathy in nursing is a tough skill to master.

I think you did just what you should have.

:angel:

115 or 90 or ... hmmm ...

What #, who to call, did that/they really MEAN _____ . Yeah, it's almost impossible at times.

Sometimes it's less about what's written, less about patient "numbers" and more about what is really going on with the patient -- that nursing "sixth sense" that saves patients & doctors. That will come in time. If calling a MD is what it takes, call them. Period.

Never be afraid to call any doctor. Ever.

FWIW — I've seen some bonehead orders. I've seen confusing, almost nonsensical (Dr. Seuss level) orders. If at any time you feel conflicted over the written orders I think a call to someone above your "pay grade" is vital (tho peers are good and I like emotional support after the fact, they cannot keep your a** out of a sling if things go south, as orders may need urgent clarification with someone who can make a meaningful decision) — that was always my practice. Period. The MD might yell, cuss, fuss — but M & M conferences or depos are ugly affairs and I intend to avoid them. So ...

I think you are doing great. I read nothing horrible here. You are aware, concerned, learning and advocating for your patient — you are actually on your way to awesome!

:angel:

[Simonesays, BSN, RN]

Agree with what everyone else has said! Definitely don't beat yourself up! It looks like you were closely monitoring the patient and reading the MD notes to help guide your critical thinking/practice.

One thing I will say is this: when there are multiple services following one patient they don't always read each others notes/agree with each others recommendations. It depends on how your hospital works but often it's still the primary team who oversees the plan of care for the patient (i.e. the nephrologist might have recommended higher BP parameters but it would still be the primary team who had the final say as to whether the patient needed an extra BP medication). You can always bring an elevated BP to your primary team's attention, just mention the nephrologist's parameters when you talk to them (also keep in mind whether the patient is symptomatic, what their baseline BP is, their trends, etc.).

Your patients are lucky to have such a reflective and engaged nurse!

[shego85]

I am sure you do plenty of good when you are with your patients. It is clear that you want to do better and so you will continue to improve. I for one am thankful for this post because it is giving me a reality check. I graduate in 6 weeks and I am terrified. I know I am going to have plenty of nights like the one you just had but it's part of the seasoning that makes you a better nurse. I think all experienced nurses have stories like this in their early careers. It is ok. You already have pinpointed your mistake and I bet you never make that one again. I don't know you but I am proud of you. Thank you for being so honest and vulnerable. Nursing is hard. Just take it one day at a time. You wouldn't be where you are if you weren't qualified to be. Take comfort in that.

[retiredmednurse]

Working nights is also different than any other shift. You did a great job watching those parameters and when you were concerned about your patient, you called. When working with new nurses on night shift, I always told them there are 3 times to call a doctor and this just takes experience, what your co-workers think, and of course the orders. Doctors do not like being called at 2 in the morning for something that he feels could have waited. One is right away. The second time, is it something I should tell the doctor not at present time, but before the end of the shift. (Depending on your hospital policy, falls are a good example for this when there is no apparent injury.) And third, just info to pass on to the next shift or a written note for the doctor to see. On nights, one is usually working with a minimal crew, so there isn't the number of nurses to ask for advice than there is on day shift. Go with the orders, and chart that as the VS were lower than the orders, this is why you didn't call. Is there a nursing shift supervisor on where you work? Pass it by her and see what she says. And sometimes, whatever you do will be the wrong choice-it happens, learn from it if you can. If this was my patient, I would have also checked the VS over the past few days. Was there a trend for the VS to rise at night? Especially the night before previous dialysis treatments? When the attendant said you should have called when the DBP was >90, did he write the order to that effect? Or did you write a verbal order from the attendant, just to cover yourself and others in the future? Just tidbits I've learned over the years of working night shift.And lastly--When in doubt, FOLLOW YOUR GUT. If your gut is telling you to call, than make that call! I would rather defend myself for making the call, than from NOT making the call.

[3ringnursing, BSN]

Nursing is hard, but before you beat yourself up any more consider this: the nephrology note said call for DBP > 115 - if you called for less than that the nephrologist would have asked why you were calling (and waking him up).

If the attending had other ideas about BP parameters then they should have been written (we as nurses don't have a crystal ball, and second guessing what every other MD associated with a patient's case would want is an impossible task to achieve).

I remember a post-op day 2 CABG patient from years ago - this particular CT surgeon kept his patients very dry S/P CABG's (he figured they went into A-fib less often). I can't recall the specifics, but I ended up contacting the cardiologist about some issue with the patient, and the cardiologist gave me a T.O. for a Rx medication. When the CT surgeon rounded he became livid, and me told me, "Too many cooks spoil the soup!". You know what? He was right.

It's difficult when an admitted patient has more than one MD writing orders - each one having different expectations about said patient. You followed the parameters for what was written. Cut yourself some slack.

And you are NOT a bad nurse! You sound like a conscientious nurse with good problem solving skills. To be admitted nowadays patient's are sicker than ever - some shifts you just fly by the seat of your pants and do the best you can (sans crystal ball or mad mind reading abilities).

[Verygreennurse]

Just want to thank everyone again. Working nights is definitely different than days. I beat myself up a lot more than I should probably (days or nights). It will hopefully become less with experience. I dont care about getting yelled at by doctors. I just need to go with my gut more.

I really love what I am doing. I know they say in nursing they eat their young but I dont think its always true (just sometimes!). As an example here. You guys threw in support for a nursling. And i cant tell you how much i appreciate it.

[karrikon]

Agreed...what they said...you did fine.

[blackberry, BSN, RN]

You ARE A Good nurse. You were listening to your gut that you should make a call. You also read through the notes and found a parameter. It sounds like the the docs didn't WRITE an order to give prn meds OR for nurses to call them when VS are above or below specific parameters. So, honey, ya did good and the patient lived.

Here's a few pieces of advice.

1. BREATH and talk to your more experienced nurses or charge nurse.

2. Look at your patient. How do they look? Do a mini assessment - lung sounds, heart sounds, pain assessment, Urine output, etc...

3. Don't be afraid to call a doctor if the patient is seeming to go downhill even if - as in your case - the bp is under the parameters.

Something tells me that you were looking at the BP trend or urine output (if any) that triggered your concern. You are doing fine.

[RNintheD]

The nephrologist knows what he/she is doing. The note said call if the BP went over, not close to. The guy had bad kidneys right? He can probably handle a higher BP. He probably just needed his dialysis. You should only worry if he is becoming symptomatic. Don't be too hard on yourself. There is never a stupid question and just remember you will forget and remember the same things over and over. You should be learning something new every day. Accept everything that goes on as a new learning experience :)