HORRIBLE DAY 2!

meandragonbrett · Sep 10, 2009

OH and what is the most accurate way to get a heart rate of a patient in rapid afib aflutter? tele monitor to count the rate? or apical ...? i tried to do my best with apical but found it extremely hard!

It can be hard to get an accurate ventricular rate via a monitor when the patient is in a-flutter. Sometimes the monitor will count the flutter waves as ventricular beats.

You need to take a minute, step back, and take a deep breath. If you know know a policy or procedure....get your charge nurse involved. Why didn't you do this? If you don't know about a medication.....don't ask somebody and take their word for it. Look it up in the computer, a drug book, or call the pharmacy! This is nothing that you need to get so worked up over and quit. Things happen on the floor....mistakes occur....you didn't harm anybody...it was an administrative error. Take a deep breath....relax...and go back to work for your next shift. Keep your head up.

Who turned the gtt off and what was the rationale? That shouldn't have been done.

WindwardOahuRN, RN · Sep 10, 2009

If the unit policy was that cardizem is non-titratable on the unit then you most certainly should have been aware of that policy. The handling of drips is different according to the area in which you are working (for example---what you can do in tele is different from what you can do in ICU which is different from what you can do in PACU, etc) and those policies are clearly spelled out. It should be in the nursing policy manuals, either in book form or on your intranet. Usually in chart form and easily printed out from your facility's intranet. I found this one on the internet---not my hospital and the policies may not necessarily apply to your facility but this is an example of what yours might look like:

http://www.smh.com/sections/services-procedures/medlib/nursing/NursPandP/126_155_Administration_052909.pdf

If you are uncertain that the monitor is picking up an a-flutter rate correctly (it may be picking up the flutter waves as QRS complexes if they are high enough) then print out a strip and figure the rate manually.

If the monitor is picking up double or triple you might want to fiddle around with the gain or move your leads around a bit.

Oh---and where was the charge nurse during all this? Advice for if this happens again: seek out the charge nurse and document her advice. Don't go bouncing around asking other inexperienced nurses what they would do. THAT might get you into trouble.

You didn't kill anyone and you learned something. In that sense you're ahead of the game.

BTW---how was the patient doing during all this?

erin01 · Sep 11, 2009

patient was fine! her b/p did drop at one point and i called the dr. Its all becoming a blurr right now. I expressed my concern to the manager that i was not aware of the units policy! Is this my fault? should i have sat down and read it before i started? I also was unsure on the chain of command. IT is all much clearer now though! all i keep telling myself is that i learned a lot that night!!!!!!!!!!!!! 1) find that freaking policy book 2) never titrate anything! 3) find out who is in charge and only ask them! 4) always read up on a med, even when i think i know=( all really hard lesson and i am really beating myself up about.

Ihoplover · Sep 11, 2009

Erin - I understand your panicky and frustrated feelings - I too am a new grad on a cardiac IMCU, that is to say the least challenging for a new grad. Not knowing the policy is not at all a surprise to me. How can we know every single policy coming out of the "orientation gate"???? We can't -plain and simple. If the conversation didn't come up in orientation then it didn't come up and this unfortunately is exactly how we learn - by experience on the unit and I definitely mean unfortunately because I can read your story and envision myself in same spot. You're not taking care of only that one patient - if you were it wouldn't have been so crazy right? No we're taking care of 3 or 4 more - all with needs and usually a challenge in every room. Last night my trach pt's IV was so tightly taped ALL around his wrist by ER at his admit that the IV solution wouldn't infuse properly AND he refused to be suctioned (we rectified this) and three of my other patients didn't have their drugs up from pharmacy - so I had to keep calling asking meds to be sent up - back and forth to room, back and forth to med room - complete waste of time for no reason (probably because pharmacy is WAY too short staffed also). My final patient - previous stroke needed his meds crushed in applesauce - guess what was not to be found on unit - you guessed it applesauce - not one container - RIDICULOUS. AND when I FINALLY found an aid and asked her to seek out applesauce in another unit (kitchen closed for nt) she was able to find ONE and only ONE left on another unit.

So............I give you my horrid rundown of just a sample of how my night usually goes to let you know I TRULY do understand. :heartbeat When you have a set of circumstances like I just described and then a cardizem drip patient is thrown at you also - and you're trying to get answers - it's just plain nuts (because....all the other nurses are working hard with challenges also and don't have much time to talk sometimes). Basically what's happening out there is that on step down units we're getting patients who TRULY belong in ICU and need more one on one care but there's either not a bed in ICU or etc so in step down we're trying to juggle a real critical patient along with 4 others (last week I had TWO patients who belonged in ICU along with my other pts - 1 had just had a stroke that day and really needed to be on NEURO ICU not on cardiac step down -grrr)

I too have felt like quitting - going to a drs office doing a day shift and not "stretching" myself anymore! BUT we've just got started and we don't need to throw in the towel yet - like other posters have said - the patient is fine and no one was hurt and as you posted we learn from every situation something valuable. I couldn't believe when I was told I wouldn't feel comfortable for an ENTIRE year on the unit - some of this is because of circumstances I already described - some of this is simply because we have a lot to learn:wink2:

A little bit of advice to you (and to myself):

1) Always show up EARLY for shift - read over the orders for the pts you'll be getting - do a couple of blood sugars on the patients even before you get report if you can - anything to get a head start in other words

2) Get report EARLY before all the craziness starts with everybody else showing up and trying to line up for each nurse to get report - so to speak (plus the nurses will love you for taking report early and you'll have more time to ask questions)

3) IF (praise God if this is possible) you have ANY spare time - during your shift to help your fellow nurse (especially charge nurse) then do it because "what goes around comes around".

4) Make a friend out of your aids by helping them when possible (i.e. I set up my room for my new admit last nt then called her & said I wouldn't need her help setting up or getting admit vitals but I wanted her to know pt was there for 8pm vitals and thanks). Offer them a piece of gum, candy, bag of chips, - just ya know show kindness - they work HARD too and alot of nurses are not so kind to them - they'll go the extra mile for someone who appreciates them (I went to pick up fast food one night & ask the aids if they wanted to order & they were amazed that they were included - how sad is that!)

5) Keep reading at home for an hour or so a week (whatever works for you) re: cardiac (I'm reviewing NCLEX cardiac materials for review).

6) Try to ask a nurse each shift a question such as "what was the one thing you wish you knew when you started working here that would have helped you function better" - (I'm going to start asking this tonite!). Hearing someone else's horror stories also helps you not make same mistake. Also asking how each nurse organizes her night or tips for ANYTHING at all is good for both of us!

7) Remember that every new shift is a new day and leave the old bad memories of what happened yesterday alone.

8) KEEP reading this website for insight - it's great!!!!!!

9) If you have a faith in God - you can do as I do each day as I enter the hospital building and pray that God will open your eyes to knowledge to glean wisdom, to bless your patients, to have a smooth shift (and I also add to help me not look so stupid )

God's blessings to you Erin - any more tips you have for me I'd happily read and take to heart!!!!!!

P.S. Anytime you want to send me a private message we can share tips, tricks or failures we've learned from:wink2:

Ihoplover · Sep 11, 2009

Erin - P.S. My unit manager just called me at home and asked WHY I didn't get the meds to my patients (2) last night - the ones I kept calling pharmacy about!!!!!!!!! GEEEEEZ - I told her entire story AND she suggested I should have told my charge nurse - WHICH I DID - and I told her I DID - sigh..............

CCRNCCU2008 · Sep 28, 2009

I think most of us have had horrible days, try to calm down step back, breath, learn and dont let it happen again. My personal worst was about 6 years ago. First week out of new grad orientation on a step down icu, 3 of my fellow staff memeber were new grads also (the charge nurse the only experence on the unit had left the unit for dinner) long story short i gave diazapam 20mg when i was supposed to give diltiazem....pt was intubated for a day then they were fine, i wanted to hide under a rock for about 6 months, almost quit but very glad i didnt. Still i get a pit in my stomach when i think about diltiazem or diazapam. Point of the story, we all are human and make mistakes try not to beat yourself up to much.

**NickiLaughs, ADN, BSN, RN** · Sep 29, 2009

I believe on a tele unit with 5 patients no patients can come to you on a drip that is to be titrated.... That would be complete negligence, the fact that a doctor wrote orders to titrate based on heart rate even, that patient should have gone to ICU, not tele. It sounds like they should have covered this prior to your being on your own.

Always look in a drug book, tho I dont think you would have got your answer, the gtt shouldn't have been stopped, but that's not your bad.

We all learn more from our mistakes than we do from our triumphs, it was a bad day, you did the best you could and that's all we can do.