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I hated being a nurse for the first time

Oh man I hope it’s OK to vent this out here and receive suggestions and encouragement!

hate is a strong word and I don’t know if that’s how I really felt but the other day was hard!

I switched from kids to adults recently and think I may want to just go back to kids. But anyway, as I was about to pull morning meds the tech informed me my patient was satting 75%. I checked him, he said he was eating and suddenly felt SOB. He’s a post op knee arthroplasty. His lungs had crackles bilaterally and no absent breath sounds. Hgb was under 8. I called a rapid response and he was put on a nonrebreather and I was told to transfuse blood. Troponins were negative at that time. A later redraw was 0.66. I’m not tele certified and they wanted to keep him on the floor because that’s where the physician was working. So he wasn’t on tele and I watched him decline. I kept calling the physicians and telling anyone around me (nurses, my assistant manager) he’s declining. I put a foley in him and after 80 lasix he still only put out 100 ml. After 6 hours he was intubated and going to catch lab. Nurses have all the responsibility but none of the decisions! I felt so helpless and alone with someone’s life in my hands in a way. I know, physicians were aware and all that it just felt like I was alone. I was really scared. And I was behind for all my other patients. Their pain meds and other medications were late and I didn’t even assess anyone yet. (My morning routine has been to pull meds and assess before I give). After I waited for the blood tx for the first 30 min I did leave him to get to the other patients and I hated to do that. No monitors on him but the pulse ox and heart rate alarm that would sound off in his room if it went out of parameters. The man was diaphoretic, BP going down even with the transfusion going in. Anyway this was my first blood transfusion and first MI and I felt alone and don’t know why my patient wasn’t taken to the cath lab or ccu sooner. They had done a stat cxr in the rapid it didn’t show a pe and ecg had showed a left bundle branch block not an mi. But still I don’t know I guess I felt like I didn’t do enough and couldn’t have done anything else at the same time?? Telling him “I’m here and everyone is watching you to make sure you’re OK” just didn’t seem like enough when he says “I haven’t felt this bad since my last heart attack”. Which I did tell everyone he said that (he said it as the rapid was ending).

edit: I wrote that kinda sloppy and out of order above, sorry!

Edited by direw0lf

amoLucia

Specializes in LTC.

OP - (((virtual hug))) for you.

Hoosier_RN, MSN

Specializes in dialysis.

If you notified everyone and documented their responses, you're good on that level. Beyond that, sometimes situations suck. Just breathe and realize that you did what you could.

speedynurse, ADN, RN, EMT-P

Specializes in ER, Pre-Op, PACU.

3 hours ago, direw0lf said:

Oh man I hope it’s OK to vent this out here and receive suggestions and encouragement!

hate is a strong word and I don’t know if that’s how I really felt but the other day was hard!

I switched from kids to adults recently and think I may want to just go back to kids. But anyway, as I was about to pull morning meds the tech informed me my patient was satting 75%. I checked him, he said he was eating and suddenly felt SOB. He’s a post op knee arthroplasty. His lungs had crackles bilaterally and no absent breath sounds. Hgb was under 8. I called a rapid response and he was put on a nonrebreather and I was told to transfuse blood. Troponins were negative at that time. A later redraw was 0.66. I’m not tele certified and they wanted to keep him on the floor because that’s where the physician was working. So he wasn’t on tele and I watched him decline. I kept calling the physicians and telling anyone around me (nurses, my assistant manager) he’s declining. I put a foley in him and after 80 lasix he still only put out 100 ml. After 6 hours he was intubated and going to catch lab. Nurses have all the responsibility but none of the decisions! I felt so helpless and alone with someone’s life in my hands in a way. I know, physicians were aware and all that it just felt like I was alone. I was really scared. And I was behind for all my other patients. Their pain meds and other medications were late and I didn’t even assess anyone yet. (My morning routine has been to pull meds and assess before I give). After I waited for the blood tx for the first 30 min I did leave him to get to the other patients and I hated to do that. No monitors on him but the pulse ox and heart rate alarm that would sound off in his room if it went out of parameters. The man was diaphoretic, BP going down even with the transfusion going in. Anyway this was my first blood transfusion and first MI and I felt alone and don’t know why my patient wasn’t taken to the cath lab or ccu sooner. They had done a stat cxr in the rapid it didn’t show a pe and ecg had showed a left bundle branch block not an mi. But still I don’t know I guess I felt like I didn’t do enough and couldn’t have done anything else at the same time?? Telling him “I’m here and everyone is watching you to make sure you’re OK” just didn’t seem like enough when he says “I haven’t felt this bad since my last heart attack”. Which I did tell everyone he said that (he said it as the rapid was ending).

edit: I wrote that kinda sloppy and out of order above, sorry!

It sounds like you did everything in your power. I have gotten in similar situations in the ER but mostly with hold patients - patients that are admitted but no rooms are available in inpatient rooms. I have had patients decline because I can’t get in touch with a hospitalist or intensivist and am stuck trying to figure it out myself or even trying to involve the ER physicians to intervene for a patient they are not responsible for. It has given me a lot of respect for floor nurses because I can’t imagine doing that on a daily basis during shifts! I think I have become so used to always have an ER physician nearby when a patient declined.

5 hours ago, direw0lf said:

Oh man I hope it’s OK to vent this out here and receive suggestions and encouragement!

hate is a strong word and I don’t know if that’s how I really felt but the other day was hard!

I switched from kids to adults recently and think I may want to just go back to kids. But anyway, as I was about to pull morning meds the tech informed me my patient was satting 75%. I checked him, he said he was eating and suddenly felt SOB. He’s a post op knee arthroplasty. His lungs had crackles bilaterally and no absent breath sounds. Hgb was under 8. I called a rapid response and he was put on a nonrebreather and I was told to transfuse blood. Troponins were negative at that time. A later redraw was 0.66. I’m not tele certified and they wanted to keep him on the floor because that’s where the physician was working. So he wasn’t on tele and I watched him decline. I kept calling the physicians and telling anyone around me (nurses, my assistant manager) he’s declining. I put a foley in him and after 80 lasix he still only put out 100 ml. After 6 hours he was intubated and going to catch lab. Nurses have all the responsibility but none of the decisions! I felt so helpless and alone with someone’s life in my hands in a way. I know, physicians were aware and all that it just felt like I was alone. I was really scared. And I was behind for all my other patients. Their pain meds and other medications were late and I didn’t even assess anyone yet. (My morning routine has been to pull meds and assess before I give). After I waited for the blood tx for the first 30 min I did leave him to get to the other patients and I hated to do that. No monitors on him but the pulse ox and heart rate alarm that would sound off in his room if it went out of parameters. The man was diaphoretic, BP going down even with the transfusion going in. Anyway this was my first blood transfusion and first MI and I felt alone and don’t know why my patient wasn’t taken to the cath lab or ccu sooner. They had done a stat cxr in the rapid it didn’t show a pe and ecg had showed a left bundle branch block not an mi. But still I don’t know I guess I felt like I didn’t do enough and couldn’t have done anything else at the same time?? Telling him “I’m here and everyone is watching you to make sure you’re OK” just didn’t seem like enough when he says “I haven’t felt this bad since my last heart attack”. Which I did tell everyone he said that (he said it as the rapid was ending).

edit: I wrote that kinda sloppy and out of order above, sorry!

First of all, I’m really sorry you had such a rough shift!

You absolutely did the right thing when calling a rapid response 👍🏻

There’s so much going on with that patient. Low hemoglobin AND low oxygen saturation is a bad combo. Add to that the oliguria and hypotension, in my opinion he really needed to be transferred to higher acuity level of care. It's impossible to understand from what you’ve described why this didn’t happen. Of course I can’t say anything definitely without knowing all the details and not having been present, so I’m only speaking in general terms. But generally speaking this doesn’t sound like a patient that in my opinion should be under the care of a nurse who’s 1:4, 1:5, 1:6 or however many patients you were assigned. And yes, I would absolutely want a patient like this being actively monitored.

What was the respiratory rate? Low saturation + low blood pressure + high respiratory rate = warning bells.

Was the patient anemic preoperatively? Preoperative anemia or a postoperative decrease of hemoglobin levels increases the risk for acute kidney injury. Comorbidities? Medications? Was the LBBB new onset? (I’m just thinking out loud here, you probably shouldn’t respond if you feel that giving away too much information might make it easier to identify your patient).

Why was the furosemide ordered? 100 ml urine in what time span?

Blood isn’t really given in a sufficient volume to have much of an impact on blood pressure if the patient is hypovolemic. If a patient is hypovolemic/dehydrated I would expect the hypovolemia be corrected before diuretics are administered. Were any fluids being infused?

About the troponins, there are noncardiac causes for increased troponins like for example pulmonary embolism, renal failure and sepsis. His shortness of breath appeared rapid onset if he was sitting there eating and then suddenly he felt it?

I know I asked a zillion questions, but no need to answer them. As I said, I’m mostly thinking out loud here. (I’m sorry if my musings include details that you’ve covered or if I’ve jumped to any erroneous conclusions. I’m extremely tired and when I am, I find it hard to read through a lot of text without paragraphs. So if I sound a bit 🤯 you know why 🙂).

You called a rapid response. Than you repeatedly made physicians and your manager aware that you noticed your patient declining. I realize this was tough for you but please don’t feel bad. You really tried advocating for your patient. I feel bad for you, thinking that you’re in this situation, being understandably stressed by not being able to care for all your other patients, and being stressed about this patient when you left him to take care of the other patients. And on top of that you administered blood for your very first time. That’s quite a shift. You did good.

Edited by macawake

I'm sorry this happened, @direw0lf. That's terrible. It's such a terrible feeling, right up there near the very top of the list of worst nursing experiences. There isn't much that evokes helplessness, sheer anger and frustration the way these scenarios do.

I have been talked down to and patronized (by an utter and complete novice provider, nonetheless), argued with, yelled at and more in trying to convey the dire nature of some situations in order to get things done.

I support you. I will say that these are scenarios where you bring out the ugly if necessary. Call another RR, call the house supervisor, point blank tell the physician "This patient is going to die. I need you to come to the bedside immediately." Any serious phrases you can think of: "This plan of care is not appropriate, the patient is dying." "I don't care what has already been done, the patient is deteriorating." "I understand that all of those things have been done but he is getting worse and is going to die." "This is not appropriate." "This patient needs [xyz] immediately, this is not appropriate care." If they keep arguing or procrastinating, call another RRT.

I hope you filed an incident report when this was all over, if not you still need to. And talk to your manager about it in person.

(hugs) for you.

amoLucia

Specializes in LTC.

direwolf - besides my virtual hug, I'll join others in saying that you really pulled a tough stint in trying to stabilize your critical pt and then trying to manage your other pts. Kudos to you.

You're right though, it's times like that that would make one question one's dedication to nsg. And desired continued commitment.

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown.

WOW!. Sounds like a terrible shift. Med/Surg is so hard, when one pt becomes a critical pt you still have your other however many pts and a double kind of anxiety builds up as you're stuck in the critical pt's room, anxiety about the pt and the voice in the back of your head how many other things are falling behind. I hope your team backed you up and took care of your other patients!

It sounds like you did everything right. It is so frustrating and causes even more anxiety when no one is taking you seriously or responding. I felt when I worked Med/Surg some doctors didn't respect my opinion and thought my pts weren't really as sick as I reported. Now that I work in critical care they respond much faster. It is so unfair. To me Med/Surg is the hardest specialty I've worked, the ratios, these situations, etc. I really commend you for working in a tough specialty and for all you did for this pt! I agree keep calling RRTs, when we get multiple RRTs on a pt we get the critical care team involved and notify supervisor we may need to clear a bed. I hope talking to manager, supervisors, RRT team can help.

You have horrible shifts every now and again. You’re an awesome nurse and did everything in your power to help the patient. I’ve had many nights where I felt completely overwhelmed, but we always get through it! It is truly frustrating though. You see your patient declining and feel helpless. That is someone’s life! I would have told my manager that I could not handle taking care of him with my other patients though.

TheAngryNurse, EMT-B

Specializes in Student.

On 8/21/2020 at 7:59 AM, direw0lf said:

Oh man I hope it’s OK to vent this out here and receive suggestions and encouragement!

hate is a strong word and I don’t know if that’s how I really felt but the other day was hard!

I switched from kids to adults recently and think I may want to just go back to kids. But anyway, as I was about to pull morning meds the tech informed me my patient was satting 75%. I checked him, he said he was eating and suddenly felt SOB. He’s a post op knee arthroplasty. His lungs had crackles bilaterally and no absent breath sounds. Hgb was under 8. I called a rapid response and he was put on a nonrebreather and I was told to transfuse blood. Troponins were negative at that time. A later redraw was 0.66. I’m not tele certified and they wanted to keep him on the floor because that’s where the physician was working. So he wasn’t on tele and I watched him decline. I kept calling the physicians and telling anyone around me (nurses, my assistant manager) he’s declining. I put a foley in him and after 80 lasix he still only put out 100 ml. After 6 hours he was intubated and going to catch lab. Nurses have all the responsibility but none of the decisions! I felt so helpless and alone with someone’s life in my hands in a way. I know, physicians were aware and all that it just felt like I was alone. I was really scared. And I was behind for all my other patients. Their pain meds and other medications were late and I didn’t even assess anyone yet. (My morning routine has been to pull meds and assess before I give). After I waited for the blood tx for the first 30 min I did leave him to get to the other patients and I hated to do that. No monitors on him but the pulse ox and heart rate alarm that would sound off in his room if it went out of parameters. The man was diaphoretic, BP going down even with the transfusion going in. Anyway this was my first blood transfusion and first MI and I felt alone and don’t know why my patient wasn’t taken to the cath lab or ccu sooner. They had done a stat cxr in the rapid it didn’t show a pe and ecg had showed a left bundle branch block not an mi. But still I don’t know I guess I felt like I didn’t do enough and couldn’t have done anything else at the same time?? Telling him “I’m here and everyone is watching you to make sure you’re OK” just didn’t seem like enough when he says “I haven’t felt this bad since my last heart attack”. Which I did tell everyone he said that (he said it as the rapid was ending).

edit: I wrote that kinda sloppy and out of order above, sorry!

Hi All,

I'm a nursing student, figured I'd do something productive over my break and walk through this patient case.
Initially he was a L TKA with:
-O2 sat of 75%
-SOB
-Crackles in lower lungs
-No rise in troponins...initially
-Low BP
-Later rise in troponins=0.66
I would guess initially a PE or Left HF (Crackles, Low O2 sat)
I guess the questions I have are:
1.)Why would the Hgb be low in CHF or an MI? Is it because he is retaining too much fluid and diluting is blood? And is that due to poor cardiac output due to left ventricle not working efficiently?
2.) I get the Lasix part...need to get rid of fluid in lungs...is that what might have caused his BP to continue to drop?

Also I'm terribly sorry you had a bad shift. Sometimes stories like this make me question nursing as a 2nd career...but I noticed that many people who are critical of themselves tend to be very competent as they always see room for improvement...which makes me hopeful about working with future colleagues .

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