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SammieRN940 SammieRN940 (New Member) New Member

How to NOT stress when a patient has high acuity

Med-Surg   (1,287 Views 7 Comments)
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I have been an RN for 6 years. But I just started in to my first hospital job. I am 4 weeks in to my 6 week orientation at my new job. It is technically med-surg but they refer to it as a surgical floor since 90% of the patients are surgical patients.

I see there are a lot of "new grad" and "new to med surg" posts so before your eyes glaze over, please hang with me.

How do I NOT freak out when I walk in to my patient's room and see a WHOLE bunch of stuff on their IV pole. I see a primary with a piggy back abx, PCA, epidural, PCO2, etc.

I am a little frustrated because I only get 6 weeks of orientation. I really wanted to follow my preceptor around to watch her time management of 6 patients and how she managed those higher acuity patients with crazy lines. But then 4 hours in to our shift we had a patient become combative and all heck broke loose and she basically sent me off to answer call lights and do damage control. I didn't feel like I got anything that night other than scared!

The next night she gave me 1 low acuity patient to take care of myself. It was super easy so that did help me get an idea for time management, charting, pain meds, assessments, etc. SO that was good. Now she has me up to 3 of my own patients that are lower acuity. But I kind of feel like I am so nervous because I know I won't get these easier patients once I am on my own. I really want a few shifts where we both tackle 6 patients and I follow her and watch her but she lets me do any of the skill based items, especially anything to do with those more complicated line set ups and higher acuity.

Last week I was caught up with my 3 patients and asked her if I could follow her around for a while with the hopes I could pick up more information and learn from her 30 years of experience. But she would brush it off and say things like, "Oh I am just giving a pain med."

ARGH! To me, a newbie, there is no such thing as, "I am just doing ....." I need help with EVERYTHING. I mean, I have given plenty of pain meds, IV push, spiked new IV bags, etc. But I still want to watch it to confirm I am still doing things right and to help boost my confidence.

IDK why, but anything more than a maintenance fluids just freak me out.

HELP!

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Is there a nurse educator who manages your orientation? Do you meet with a manager to discuss your progress at set points during orientation? I'm a bit worried that you are at week 4 of 6 and only taking half an assignment. Do you work 12 hour or 8 hour shifts, and how many shifts do you have left before your orientation is set to end? I would strongly suggest that you ask to take 4 patients for your next shift. If you meet push back from your preceptor, then it is time to talk to your educator or manager. If you work 12 hour shifts, and have 6 shifts of orientation left, then set a tentative goal to take 4 patients for your next shift, then 5 patients for 2 shifts, and the entire assignment of 6 patients for 3 shifts (so that you can get a feel for what the workload feels like with the help of your preceptor).

At my current job, a typical orientation for experienced nurses is 6-8 weeks depending nurse comfort, so speak up if you feel like you need another week!

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These are all things that you need to tell your preceptor. It's very possible that she just doesn't think you need as much help as you do. I recently stepped into the role of precepting on my unit and its actually a lot harder than I had imagined. It's difficult to know exactly where a new grad is at in their comfort level andknowledge because some new grads pick things up much more quickly than others. But I guarantee your preceptor doesn't know any of what you posted unless you tell her. And don't be afraid to ask for another week or two of training. If your unit refuses to give you the training you need to be successful, it can be a red flag. Our trainees get at least 8 weeks, sometimes 10. For the last two weeks of your training, your preceptor should essentially be sitting on her hands and letting you take the patient load. That way you can get a true sense of what it will be like on your own, but you'll have her there to help you or answer any questions.

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First thing: Stop being anxious. Anxiety actually impairs your ability to form new memories. Remember that every single nurse has been in your position. These other nurses are not smarter or superior to you, just more experienced. You will get there.

The hardest thing about being a new grad is that you are slower at tasks, which makes it even harder to take a breath, look at the mess of an IV pole, and work through it. You want to rush, but that makes you anxious, which leads to a mistake or forgotten supply, then the task takes even longer.

I used to have a lot of TPN and ancillary IV nutrition patients all due at the same time on night shift. I would go in and have to tell myself: This is what I am doing right now and I cannot think about other things. Hang the wrong filter in the wrong place and you have to start over plus sometimes clean up a sticky mess. Forcing myself to breath, focus, and do one thing carefully though quickly was very helpful.

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First, take a few deep cleansing breaths. Then, analyze the situation. Trace all lines and label them. I also move hanging IV meds on the IV pole so that they're directly above the channel that operates them.

Next, do your research. You have resources. Including pharmacy and the written policies and other RNs.

Sometimes, I have to tear it all down and rehang if because it's incorrect.

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You sound overwhelmed by the whole process (understandable)--can you break things down into chunks? You can't let any one chunk dominate your day, but if you do each chunk the same way each time, it helps it become a more automated action. The sheer number of tasks and sub-tasks we do just for one patient is basically indescribable! Some examples that show you just how many steps I'm talking about but how you could develop a routine:

1) My patient asks for a PO pain med. a) Tell patient I will check what is available and b) ask patient what they want to drink to take the med. c) Check eMAR, verify it's available, d) go to med room, pull med [get a witness if needed; don't waste later unless it's an emergency], e) grab a med cup while in there, f) stop at the ice machine for a cup of ice and g) beverage, h) bring computer to patient's room, i) hand hygiene, j) scan bracelet, k) scan med, l) chart pain assessment, m) give med, n) log out of computer. Before leaving, o) ask patient if they need anything else right now, p) tip their foley if needed (I'm used to hourly monitoring in the ICU), q) make sure they have their call light and the bed alarm is on, r) leave room, s) hand hygiene.

2) I need to give an IV push med: Assess all IVs at the beginning of the shift so I have some hope they will still be working. Then: all of the above stuff with the eMAR; while in the med room grab alcohol preps and flush syringes, scan med appropriately in patient's room, flush and re-assess IV site, give med, flush again, pick up waste for the sharps container in one hand and other waste for the garbage can with the other hand, get rid of all waste, etc...

3) My patient has an IV pole with a lot of stuff on it. I have basically ONE WAY that I like my poles to be. Taking a few minutes to trace lines, make sure everything is labeled and untangled, and hung where I want it saves me a lot of headache and mental energy. Try to pick a set-up that works for you (and isn't wildly different from what everyone on your unit does!). If it seems like most nurses put the tube-feeding pump on the IV pole with the feeding & flush bags on the rear hooks, put them that way EVERY TIME. If you use separate pumps for pain infusions (my hospital does), put it in a standard location that allows the most room for the patient to reach the PCA controller but also allows you to check the settings/volume as often as required. Get RID of expired tubing, tubing that nobody red-capped, weird sticky pieces of tape, PCA pumps that were dc'd yesterday, etc... Be a little creative--our hospital beds have pop-up IV poles at the head of the bed. Sometimes I put pain infusion pumps there, especially for bilateral peripheral nerve blocks where the tubing would be all over the patient's body if it was coming from a pole at one side of the bed. (Also, when you trace out those lines, assess the sites they correspond to.)

The best way I can explain it is a lot of what we do is pattern-based. Right now, you probably feel like you don't have a pattern for anything. If you purposely work on developing patterns, they can save you a lot of headache (forgot a med cup! need to hang a med and there's no med-line in here!). They can also help you spot divergences from the pattern more quickly--you know how you might be struggling with something and you finally call someone else for help and they walk in and spot the problem in 2 seconds? When you have a firm idea of how something is supposed to look, it's much easier to notice when something is "off." Eventually, this will help you spot problems (how long has my patient's SpO2 alarm been silenced? who connected the PCA to the intermittent med-line?) as well.

Another thought: It can be hard when you're on orientation to feel like you have full ownership of the patient's care and the space you're working in. Like, you might feel like you need "permission" to move the feeding pump or take un-needed supplies out of the room. However, you are in charge of this space and the care of this patient. Move the feeding pump!

Good luck to you!

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Talk to your preceptor as well as your manager. They want to help you. Med surg is crazy but you will get the hang of it. I actually asked for an extra week of orientation and it helped me lots. I used that week to do everything 100% and she just was there Incase I had a question I couldn’t find the answer to. It gave me more confidence. No shame in asking I promise they don’t mind. 

Ask ask ask. Don’t feel embarrassed or dumb. Ask her to stand next to you and watch you use equipment. It can be intimidating just to see 10 things hanging. One day I went in the utility room for a little bit and played with the equipment so I could get a hands on feel for how to manipulate it and see how it works. 

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