How to keep anxiety in check

[Lynden74, BSN, RN]

I've been a nurse for 15 years and recently oriented to our small rural hospital's ICU. During my orientation there were usually no ICU level patients and my orientation was choppy as I was filling in shifts in my old unit. We often have overflow med-surg patients or our ICU patients are not very critical. 

I'm interested in knowing how others manage their anxiety when you do have a critical patient. I often have no support or the support I have is a nurse greener than me or a house supervisor with med-surg and OB as her background. 

For example, recently admitted a patient from ED with urosepsis and cancer with mets. On nasal cannula O2 only. BP on admit to ICU 80s/50s, MAP >65 - ED nurse attributing recent pain meds for opioid naive patient. Within an hour BP dropping, MAP <60. No change in mental status (however started out below baseline), heart rate stable. Orders for NS bolus only. Supervisor leaves unit to go to the ED (not for an emergent situation) and my coworker just received her own admit and is less experienced than me. I have no resources and I'm terrified he's going to start crashing. He did end up stabilizing and but I was in such a state of anxiety during those couple hours I had difficulty making it thru my next shift from exhaustion. 

Any suggestions as to how to keep my head about me, remain calm and effectively see the situation for what it is? In hindsight his HR didn't change, MAP was stable but lowish and he remained coherent throughout so maybe I should have not been so worried? I feel part of the problem is no one to bounce ideas off of and lack of education. Open to any and all ideas...even if you think it sounds like I'm not cut out for this work.

In my defense if pressors were the next step I would have been mixing them on my own. I put a Foley in him during this time to monitor U/O even tho he refused in ED. One IV was subq so had to start a new IV.  And my patient down the hall was alarming with a systolic BP of 200 and I couldn't address it.

[overtonis]

I believe every nurse should be skilled/advanced in meditation. It has the ability to heal and eliminate stress. In all of my years of working in ICU...its the only thing I found that truly was game changer. 

[marienm, RN, CCRN]

This is going to sound mean, but it sounds like your hospital isn't prepared to have an ICU?  They're leaving you out there with no support in situations you don't know how to manage.  That's not fair to you or to your patients.  I don't think this situation is sustainable but in the meantime I do think that having a better idea of what to expect and not doubting your skills might help:

1) Break down your skills into component parts:  It's not hard to mix a bag of pressors but you do need to know how much of the drug to put in how big of a bag so you can program it correctly on the pump.  If you don't have this reference info available, find out how to get it.  Practice putting in IVs/foleys/NGTs if you need practice.  If these supplies aren't readily available on your unit, find out how to get them quickly so you're not wasting time chasing supplies.  Practice weird stuff that everyone struggles with in an emergency like how to drop the head of the bed flat or take off the headboard for intubation!  

2) Know your resources:  Who else is good at putting in IVs?  It might be someone who has less experience overall, but is good at IVs...Call them up if you are struggling!  Find out whether anyone can place them with ultrasound...if not, can your unit get trained?  Does your hospital have a rapid-response team?  Can you call them for help or advice (or is it an overworked ED nurse with a full assignment already?)  Who are your medical providers and how do you reach them?  Are they on-site or remote?

2.5) Know the order of operations: Are you allowed to start pressors through a PIV?  If not, who places the central line?  How do you reach them? How much lead time do they need?  How long does it take to get an xray of the CVC after it's placed? 

3) Know what to expect:  Get some education so you have a better idea of what to expect in a critical situation!  Joining AACN isn't too expensive (maybe you can get your hospital to pay for it but it's less than $100/year) and you can get access to their CEUs for free.  For example, with your septic guy, fluids...sometimes a lot of them...are an appropriate response to sepsis.  Other things you might expect (and anticipate them so you can try to plan!)--I&O monitoring (your Foley!), serial blood draws for lactic acid/procalcitonin/coags depending on what else is going on, imaging such as chest xray or abdominal CT, starting broad-spectrum antibiotics after drawing blood cultures.  There are probably Youtube modules on sepsis out there that you could watch to review the pathophysiology of sepsis.  

As I said, I think the situation your employer has created is inappropriate.  (Maybe I'm naive?  I've only worked in a big teaching hospital!)  You can do the things I suggest above to prepare yourself; being prepared never hurts and can help you focus on the task at hand without feeling like the task itself is a hurdle.  But you're fighting an uphill battle and you need more people on your side.  Do you have a manager?  Charge nurse?  Training department?

[Lynden74, BSN, RN]

Thank you, marienm, for your reply. It helps me to feel validated in my concerns. Over and over I would just get a confused look when I would express my worries. I started to think I was just over reacting.

I do have a ton of educational resources (and utilize the ICU Advantage Youtube channel) but until I have hands-on experience it's hard to pull it all together. Finding the time to learn when already working so many extra shifts has been hard.  My basic nursing skills are solid and I'm very focused and quick when under pressure. I do like your suggestions for practicing the "weird stuff".  

When I feel completely unsupported and fearful I'm toast the next day.  Meditation is high on my to do list and am moving it up to 1st place to help me to remain some sense of calm through future situations. 

Again, I greatly appreciate your validation. Your response didn't sound mean - it was exactly what I needed to hear to help reassure myself it's not just me. 

Thank you!