Instructor reamed me even though nurse said I did right thing..what do you think?

Nurses General Nursing

Published

Specializes in CVICU.

This is LONG because I want to give a backstory on my patient so maybe you can see my thought process. :redbeathe

I'm a second semester nursing student on a cardiac tele/step down floor (depends on who you ask :rolleyes: ). One of my patients today was transferred up from the CCU last night. Her history-admitted for NSTEMI, also, HTN, high cholesterol, renal insufficency, and had had a stent placed in her LAD two days prior. She had a hep drip going, her 9 am meds were Plavix, aspirin, acetylcystine and metoprolol.

During AM shift report, the patients nurse and I were getting report from the night nurse. The patient's granddaughter came out and said her grandmother couldn't breathe. I followed the nurses in the room. They asked her if she was anxious. The pt said yes, so they got her some Ativan. you could her the patients wheezing across the room and she was obviosly having problems breathing. Anyway, i finish getting report. I had three patients, she was my first stop to assess because, well, she couldnt breathe!

I heard crackles in her both lower lobes and rml. She aslo had wheezing in her upper. She had thready pulse in all 4 extremties, her 02 sats stayed around 93%, her RR was 18, 90 HR, 112/75. She had a cannula on with 3L of 02 going. She complained she was still a little SOB, but besides that she was "feeling better" By that time her daughter had arrived and said "she must have been anxious, the ativan is helping"

30 min or so later, The CNA ask me to help her off the bedpan. Well lo and behold, there are giant clots of frank blood in her stool. besides the obvious black tarry GI bleed stool, I have never seen that much stool. Her doctor happened to be outside her room, so I told him that the patient has bloody stool. he asked if it was a lot, I told him i thought so. He looked at it himself and said "thats not a lot, but thanks for telling me." :confused: I thought it was a lot...but I also dont have anything to compare it to. The pts vitals were fine at this point, still a little SOB, but her 02 sats were fine and the wheezing had diminished, so I decided to just chcek on her often.

ANYWAY, i go to give her 9 am meds about 20 minutes after the bedpan, her BP was 118/78, her HR was 92. In the 15 minutes I was in there, she deteriorated. I made sure her cannula was on, not kinked, and in her nose, and raised the HOB up. She drank her aceytalcystine, took her oral meds, and the whole time kept complaing of SOB. her wheezing started back up again. then she broke out in tears because she was distraught that she couldnt breathe and she didn't know what was wrong with her. so I left to go get a pulse ox monitor. I was gone all of 1.5 minutes. I put it on her finger and it was 78%. :eek: I waited about 10 seconds to see if it would go up, and it got to 80%. No bueno. So i went and got the nurse. the nurse upped her 02 to 5L, raised the HOB higher than I had it and asked me to retake her bp and we moved her up in bed. The 02 sat got up to 90%, I asked the nurse if it was ok for me to leave since I was gonna be late with my other pts meds. So my nurse stayed and helped the pt.

So 15 minutes later I'm updating my insturctor that pt. She asked if I listened to her lung sounds and counted her respirations after i took her pulse ox. HER O2 SATS were 80%!!! I wasn't going to stand there and count her RR and listen to her lung sounds when the pt looks like death and the pts daughter asks me to get the RN!! My instructor got all melodramatic and used words like "abandonment" and putting your patient in danger. :crying2: I'm a second SEMESTER nursing student taking care of a pt who should have never left the CCU to begin with, I am freaking out because I've never had a pt detiorate so rapidly. My main concern was my patient getting oxygen, so I went and got the more expirenced nurse. ***** Please keep in mind, it takes me 2-3 times as long to get RR and lung sounds because I'm a 'nurse-ling'. you guys might have been able to do it in 30 sec, but it would have taken me 2 minutes.

Well while my instuctor is ripping me a new one, the nurse and doc and charge walk by and apparently my patient is going back down to CCU r/t pulmonary edema. My instructor GLARES at me and says, "see, now she's going down to CCU" Again, ***!!!!! NOT my fault she had a new onset GI bleed that the doc wasn't worried about, and me listening to her lung sounds and taking her RR wouldn't have prevented her from having to be sent down there. Right?

Anyway, when the smoke had cleared, I asked the nurse. She said she was glad I came and got her because the patient had deteriorated so rapidly.

So, LONG STORY short...(not really lol), should I have stood there and taken her RR and listened to lung sounds, or was I right to get the nurse? My instructor made it clear to to listen to lung sounds and get RR . And even othough she is technically right, when you can hear the pt wheezing across the room and you can see that the RR is rapid and labored, and when you pt is going to sh*t, should I really take the time to that? :confused::confused::confused::confused::crying2::crying2:

*p.s. i'm still learning, so any CONSTRUCTIVE :D criticism is welcome"

Up Vote Up Vote ×

Whatever you do, DO NOT, let this turn into a battle of wills with this instructor. Remember that she holds your future in her hands. Don't make her angry. As a matter of fact, you should have as little to do with her as possible. Now it is time to lay low and hope another student gets in her crosshairs.

Up Vote Up Vote ×
Specializes in Advanced Practice, surgery.

If I had been her nurse I'd have wanted to be told ASAP that she was deteriorating. An acutely unwell and deteriorating patient needs emergency treatment quickly,

Up Vote Up Vote ×
Specializes in Utilization Management.

Heck, I thought you did great! You had to get help for the patient, and you did. As a nurse, I would've wished someone did ABG's and got a CXR as soon's the first problem started, but that's just me, because I know how fast these folks can crash. But your instructor was missing the point-- even in a code, your first priority is to get help.

Another thing to keep in mind: O2 sats are not that reliable when the H&H is dropping, so if you have someone who looks pale and is short of breath, might be a good idea to get an H&H along with an ABG and a CXR. ;)

Up Vote Up Vote ×

The only thing I'd recommend is that you stay with the ailing patient instead of tending to the others. Meds can wait until the crisis is over. Once you got the primary nurse, you could have stayed and assessed the patient...lung sounds, RR...while she was present.

Try not to beat yourself up...you're new and learning.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, Emergency, SAFE.

I think you did a good job, especially for being 2nd semster. You paid attention to her, tried to work out any difficulties she had (putting up the HOB, asking about anxiety etc) and when you saw her pulse ox was low, you got the nurse immediately.

However, id agree with Caliotter. Dont turn this into a match of wits with the instructor, b/c you will lose (or fail!).

But kudos to you. You have the makings,..dont give up.

Up Vote Up Vote ×

Cooperate to graduate is the mantra of the day. You can have a pile of evidence to support your position and it would still go poorly for you. It sucks, and students pick up allot of false information along the way, but you do what you must to graduate.

Up Vote Up Vote ×

I'd agree with caliotter3 about this. It's clear that counting respirations would not have helped your patient much in comparison to reporting the distress. It's so hard to find the will to avoid being hurt by this kind of treatment, but you can do it. Once you master that, your life will get so much richer! Hang tough and blow off some steam with some good music or something once in awhile (Turn Up The Radio by Autograph works for me :cool:)

Regards,

Mukfay

Up Vote Up Vote ×
Specializes in CVICU.

Today was our last day of clinicals for this semester :yeah:And trust me, I know of some students who have been 'singled out' for "rocking the boat". I do not want to be that student!!! I was p*ssed, but I respect my instructor so I do listen and take to heart what she says and I have learned a lot from her.

Another thing to keep in mind: O2 sats are not that reliable when the H&H is dropping, so if you have someone who looks pale and is short of breath, might be a good idea to get an H&H along with an ABG and a CXR.

thanks angioplasty!! I can't order labs as a student, but that's good to know for my future!:redbeathe

The only thing I'd recommend is that you stay with the ailing patient instead of tending to the others. Meds can wait until the crisis is over. Once you got the primary nurse, you could have stayed and assessed the patient...lung sounds, RR...while she was present.

Thanks, icu. I know that the meds could have waited, but our instructors are big on us getting our meds on time! One of my other pts was on cardizem, and yesterday his HR went up to 180 in SVT because the other nursing student was late giving it to him! My ailing patient was more important, but in my newbie mind, b/c the primary was there doing her thing, i was in the way and I needed to go give meds anyway. coulda, shoulda, woulda. Every clinical day I learn something new. :) :idea:

Up Vote Up Vote ×
Specializes in med surg, ccu, icu, nursg home, md offic.

I think you did great. I also think the bedside nurse dropped the ball. The wheezing should have been addressed immediately. Wheezes are not treated with ativan.. Had the pt had a neb, maybe some lasix it is possible that all the drama could have been avoided. Stay out of that instructors way. You need to kiss butt the rest of the semester. Good Luck

Up Vote Up Vote ×
Specializes in med-surg.

My two cents. The patient was rapidly deteriorating, and as her nurse, I would have wanted to know immediately, though next time, I would suggest hitting the call button and requesting the nurse/help immediately rather than leaving the patient (you never want to leave a pt who is in respiratory distress). As a nurse, I would not have bothered with the lung sounds until after ensuring her O2 sat had increased. As for the RR, it needs to be taken, and is something the doc's will ask about, though I would not have stopped trying to increase her O2 sat while taking RR (you said that you checked O2 cannula and waited a minute to see if O2 would increase, I would suggest while waiting that minute, count RR). As for the instructor telling you the pt going back to CCU was your fault, from the information given, I would say no, it's not. Regardless of you listening to lung sounds and RR, that patient was headed back to the CCU.

All that being said, don't get into it with your instructor over this! I agree with the above poster - this woman holds your future in her hands. Lay low, and hope her anger passes. Learn what you can, don't let this get you down, let it blow over, and move on with your career.

Up Vote Up Vote ×
Specializes in CVICU.
Wheezes are not treated with ativan.

Thank you!!!!! I couldn't believe they dismissed her SOB as 'anxiety' and just gave her the ativan. I told my instroctor that and she was like "They didn't even listen to her lungs?" Oh, and my pt was on lasix, the doctor had d/c'd it the day before :down:

Up Vote Up Vote ×
+ Add a Comment