I feel like I'm sinking!

[j-low, ASN, BSN, EMT-B]

I used All Nurses throughout nursing school. Since I have become a nurse, my visits have not been as frequent. I read a recent thread and the many supportive responses to it and realized that what I'm feeling would be best received by all of you, so I decided to write this.

I began working at a level 1 trauma center in the ER as a new grad RN last October. I had worked (and still do) EMS 12 years prior so I felt that the ER would be my home. Now....now I'm not so sure how I'm feeling. I feel that this learning experience could not be topped by another facility. The vast amounts of things that I am exposed to will make me a better nurse one day. My biggest problem that I had when I started, and that I am still having, is prioritization. So my question to you all is this-how do YOU prioritize? Some things fall out of the Maslows Heirarchy of Needs and ABC's categories.

It is currently trauma season, and discharge is a priority at our facility. We often hold patients for long periods down in the ED. There are times that patients are down-graded and discharged after being admitted and they are still waiting in the ED because there was not a bed upstairs. The minute your patient is up for discharge, your room is automatically double-booked. So now you have one to discharge and to prepare for a new one. The new ones sit in the hallway until the room is clean. But I can't just NOT see my new patient just because the room isn't clean yet! My discharges are rushed, if it gets too involved I find myself panicking because I'm not getting rid of my patient fast enough and I already have new orders put in on the new one. We are so short that we often have 5 and 6 patient teams (common, I know). But I don't feel like I can practice safely. I cannot give adequate attention to that many people at one time. And if someone asks for a blanket, water, or a bedpan, my thought had become "this is going to take up so much time, I have so much to do". There was a shift I had two vent patients and an additional 3 patients. Both vent patient's BP's crumped and I was running around trying to titrate drips that I was clueless on how to titrate properly. Last Sunday I had three patients get clean rooms at one time. We have 20 minutes to call report and take them upstairs. I was immediately double booked and hadn't even called report yet, let alone taken them upstairs. I then had three new patients waiting in the hall looking at me wondering why I hadn't spoken to them yet, and three to take up. And of course, a nurse must travel with anyone who has telemetry ordered. In my rush, I saw an order on my screen and all I saw was "K". I hung a run of KCl. While on the phone with the receiving RN, I realized that the order was for KPhos, not KCL. I immediately stopped it and notified the admitting MD. I know no harm was done, but I also didn't benefit my patient. So, I ask you, when things get crazy, how do you do it? I'm just feeling very dejected and like I'm sinking. My co-workers are helpful. When they have time. But to be realistic, there are times it gets so busy that it's very nurse for herself (or himself). I do feel like I improve every time I go back, but it's the getting back part that's hard. I know that I have made huge improvements from my first day on the floor. It's just that some days I'm not so certain that patients are actually benefited because I was their assigned nurse.

[kiszi, RN]

Both vent patient's BP's crumped and I was running around trying to titrate drips that I was clueless on how to titrate properly.

Hi there! I have to say there is a lot about your post that concerns me but this one set off warning bells. You should in no way be titrating drips you are clueless about. It sounds like you possibly had a sub-par orientation, but that is not any reason to be messing around with vasoactives you aren't familiar with. Is there no charge or resource nurse to go to for help? Your inexperience combined with what looks like an unsafe assignment sounds like a disaster waiting to happen.

If I could offer any advice here it would be to slow down. It may seem counterproductive, and I believe you when you describe the frenetic pace of your ED. But if you can slow your mind down and really see what is going on for a moment, it can you help see more clearly what is the highest priority at any given time. It will also keep your patients safer if you take a moment to look up unfamiliar drugs. Does your facility have an IV drug reference with drip parameters and titrating guidelines? If not I highly recommend finding what your facility does use as a reference or create your own.

I really feel for you as it sounds like you're in a tough environment. Just remember that if you take five extra minutes to get the patient to the floor or have to pass that IV antibiotic to the floor nurse to hang, the patient will still be ok.