I just need to share my probs (long)

[whatnext]

I am a new grad going through critical care orientation in CVSU, started 7/24/06. I am being flipped between nights and days, will eventually work nights. I am one of the only new RNs being flipped, but they said it's because there aren't enough preceptors. Anyway, I have been a mess the last few weeks--depressed, crying, can't sleep, etc. I have always been a night person, but lately it's easier for me to get up early than stay up all night. My self-confidence is decreasing, too. Instead of getting more confident, I feel lacking in my abilities every time I work. I was one of the top students in my class, but now I feel like I don't know anything.

I didn't have much experience with dressing changes and wounds in school. Today I did a wet-to-dry, which I know how to do. The problem was, it was an infected wound (the patient was a CABG and she's back b/c infected sternal incision). My preceptor didn't watch, but asked if there was an odor and how it looked after. There wasn't an odor, and I thought it looked ok--no pus, drainage, etc. There was some yellow (exudate?) tissue, I tried to clean it out but it wouldn't budge. When one of the MDs came later, he said we need to do more wound care and change it because there was the yellow tissue, etc. I feel like I did something wrong, missed something. I should have brought my preceptor with me. My preceptor went with me to put a new dressing on with the new orders. The doc wrote for more cultures, so she busied herself getting those and didn't say much to me. I only had an 8 hour shift, so it was time for me to leave then. She just said goodbye. She never tells me if I should do things differently, or if I'm doing them correctly.

There is a different pt that had to stay b/c of an infected leg incision that I had the other day. She didn't have the infection when I had her, not that I know of anyway. I had previously asked my preceptor if I should look under dressings when we do our assessments, but she said not really. The pt I'm talkng about had an ABD over her incision, with some of it exposed to air. The part exposed to air looked good, and I peeked under the corners of the dressing to see some of the incision, which also looked good. The nurse before me had just changed the dressing, so it was ok for another day. That was last Thurs pm shift. She was supposed to go to short-term rehab Fri. I came back this am (Mon) and found out she was still in our unit because of an infection. It wasn't found until just before she was going to leave--the husband had already gone to get the car. Luckily the she found the infection b/c she decided to change the dressing before the pt left. I feel like I failed the pt. Now I will look under dressings to view the wound myself.

I have different preceptors for nights and days, and so far have worked with 4 different nurses, plus 1 from a different unit because mine left one night after 3 hours--the nurse from another unit had never been to ours before, and the other nurse working was a travel nurse. Our unit is only 12 beds, and sometimes they close beds down so we only have a max of 4 pt/nurse. I like the unit, feel like it's a good unit to learn on b/c it's not completely crazy all the time.

When I ask, my am preceptor says I'm doing fine. I don't feel I've done anything really wrong, but feel like I'm missing something or not getting the whole nursing thing. I feel like quitting, but I didn't get through nursing school to quit so early. Right now I should be sleeping since I have to get up in less than 5 hours, but I was in bed thinking about all this. It helps to come here and see I'm not the only one struggling, and that some day it'll get better. I feel like I'm missing the easy things though, and so far my pts haven't seemed that complicated. I hardly see my husband anymore and have no personal life because I'm so tired all the time.

How do you get through these months without going crazy?

[NotReady4PrimeTime, RN]

Take a deep breath. You're being way too hard on yourself. You say your preceptor came with you and the dressing on your lady with the CABG was changed again and cultures sent. What did your preceptor think about the appearance of the wound? The yellow "tissue" you talked about could very well have been fat! Since it didn't come off when you tried to remove it, that would be my guess. You need to talk to your preceptor and ask her for feedback. If she is one of those people who never says anything direct, ask her direct questions. "Was my technique okay on that dressing change? I thought the wound looked...., what did you think? I didn't smell any odor, did you? What do you think that yellow stuff is?" Help her understand that you can't assess your own practice without some feedback from her, because you're a new nurse and you're still finding your feet!

The other patient you mentioned... you cared for her on Thursday and her wound looked healthy to you, at least the part you could see. Another nurse had just changed the dressing, so the onus was on her to describe the appearance of the wound and make note of any concerns. (It's actually not a good idea to continually lift a dressing to look underneath because it exposes the wound to whatever is in the air.) Now the lady has an infection. Was she febrile on the day you had her? Was her WBC elevated? Did she have a lot of young polys on her diff? If she didn't have any of those signs, then you didn't miss anything. If she did, then all the nurses who were assigned her care missed it too.

Nursing care is a 24 hour a day deal. We're supposed to share the responsibility of care and the work that goes with it with the others who are assigned the patient. We can't do it all, all by ourselves. The learning and growing and developing your skills thing isn't an event, it's a process... one that will last for the entire length of your career. No one graduates from nursing school a "complete" nurse, and no one takes on a new job and does it perfectly from the first minute. When you did your psych rotation, did you learn about general adaptation syndrome? Or the Life Events Inventory? You and all the other new grads like you are going through a huge adjustment from student to practitioner, and if you look at the items on the Life Events Inventory, you'll find that things like starting a new job in a new field, changes in social activities, changes in income and changes in work hours are all on the list. It's really hard to get a new career off the ground, as you're learning. You will get through it. Life will settle into a routine, you'll feel like you're doing a good job, and you'll start to feel better. Give it time. Crying isn't a crime.

[RNinSoCal]

WOW! I can't imagine having to switch from days to nights continuously. I work 8 hour nights and I need 2 days in between to recover enough to function during the day. I used to do 12 hour shifts ( I have done both days and nights) and no one ever expected me to switch from days to nights like that. Our preceptees do 1/2 of their orientation on day shift and then switch to nights for the second 1/2. In fact that was the way things are done at every hospital I have worked or studied at. It is really unfair for your facility to expect you to be able to learn and function well with a schedule like that.

If I were you I would talk to the nurse manager about staying on whichever shift has preceptors until a stable preceptor can be found on the other shift. It is not a matter of what you are capable of, it is a matter of the limitations of the human body. You are only human and you need rest. Lack of sleep and lack of continuity in preceptors is what is making you doubt yourself.

Hang in there. Everything gets easier after you get into a stable sleep pattern.

[whatnext]

Thank you so much for your replies. I know I am too hard on myself sometimes, especially when I'm tired and unsure of myself. Today went better, despite the 4 1/2 hours of sleep I ended up getting. I was busy all day long and thought my head would explode if I had to do one more task without getting caught up, but things went better considering everything going on. One pt was on contact precautions for hx MRSA, had an insulin drip, q 6h dressing changes (which I had to redo after the doc took it off to examine the wound), was getting vancomycin and another antibiotic that required starting another IV even though she hardly had any veins left (I had to call an IV team and they had probs, later tried to get a PICC, but no success), and it seemed I was in her room most the time. It seemed like once I left her room I had to go back in, and the time putting on and taking off the gown and gloves adds up. Luckily my other 2 pts were stable and not too needy.

Janfrn,

I've tried the direct approach w/ that preceptor, which sometimes works, but other times I still get vague answers. I didn't think it'd be a good idea to continually lift up a dressing for the reasons you gave, but now I feel I should do it at least once a shift even if the dressing doesn't require a change. I looked at her temp and her labs which were at the upper end of normal, so maybe the infection was in its beginning stages. The nurse who had changed the dressing is in orientation too and had asked a different nurse to look at the incision b/c she thought it looked strange, but the other nurse said it was fine--she didn't tell me that until yesterday when we found out the pt was still there. Looking back at the whole picture maybe we could have caught this earlier. It really does take teamwork, communication, and looking at everything as a whole. I've learned from this, though.