I'm a RPN student, just entering pre-grad. I've been assigned to a step-down ICU (acute respiratory), and I've been having some serious personal identity and self-doubt issues since the commencement of this placement.
I've never been in such an acute setting. And I thought it was what I wanted. I thought I would be up to the task.
But the reality is -- I'm not.
Not only are all of my patients dying or coming close to it, I screw up on the most basic of things (like, ugh, leaving a side-rail down and leaving the room), and it seems as though these screw ups keep happening.
I'm so terrified of doing something wrong that I have to ask clarification from my preceptor all the time, and I can see she is getting annoyed with my constant need for affirmation of the most basic of directives. The nurses keep asking me if I've ever had a placement in a hospital before, which should give you a pretty good understanding of just how idiotic I am.
One of my patients has severe hypoxia and shortness of breath secondary to pulmonary fibrosis and dementia. She was satting at 92% on room air during my shift yesterday. I wrote this down on the vitals flow sheet, and left it because I had read in the physician's orders (or so I thought) that she was to be kept between 88% - 92%. Today we got onto the floor, and she was drowsy, completely out of it, and deteriorating quickly. She was on 2L of 02 via nasal prongs, and satting at 96%. My preceptor was very shocked while we were assessing her, and said that it was because I hadn't informed her that the patient was satting "so low" yesterday, and that was why the patient was deteriorating now. I was ready to throw myself out of the window when I heard that -- it made me want to die, to know that it had been my actions that created this downward shift in her condition.
Also, my preceptor doesn't like how I perform patient care -- she implies that I am slowing her down. Today I changed two patients who had become incontinent of stool and had leaked all over their bedsheets. I had changed them earlier in the shift, and when my preceptor saw what I'd done, she got very angry and told me that, in an acute setting, there was no time for that to be done twice. If I'd already changed them, and the amount of excrement was livable, I was to leave them sitting in it because there were more important things to be done.
This is just a small incidence of the philosphy I have been exposed to on this unit.
I feel this isn't what nursing means to me.
And I feel like it's time to drop out, get an $8 an hour job, and turn my back on this wretchedness once and for all.
as a nurse educator and an instructor it seems that you are not being supported by your preceptor. i hear from your post that there is a communication break down between you two. the circumstances with your patient being drowsy can be caused by many factors and there is not enough information for anyone to say what the issues was/is. ie what were the blood gasses is the patient going septic? there are many unanswered questions.
for your preceptor to point an finger at you is unacceptable even if you had part in it. that is not a good learning environment and not supportive of your learning. your preceptor needs to be more tuned into her/your patients and ask question to facilitate your learning needs.
if you have an instructor i would suggest that you talk with her/him about the situation. i would also suggest that you sit with the nurse manage and preceptor write out learning objectives. you need to build up your skills and confidence. with your learning objectives i would suggest taking care of 1-2 patients for a short time and then add more as your skills improve. this will help build your confidence as well.
here is a suggestion to start.
day one
rant will assess patient at....(add time) this assessment will be done with the nurse and will be discussed and compared between the preceptor and preceptee. differences will be talked about and the preceptee will then review the assessment again asking questions during the assessment.
rant will help pass medications at (add time) the medication pass will take no longer than ............. mins depending on the route and number of medication. the nurse will check all medication prior to passing of the meds and verify the route, dose time and reason for administering the medication.
rant will pass meal trays at..... time
you get the picture.. i hope this helps you
this will show the nurse manager, instructor and preceptor that you are engaged with your learning and taking responsibility for your learning
There isn't a nurse anywhere who hasn't made some basic mistakes, like forgetting call lights or side rails. I think you've gotten some great advice about mental checklists before you leave the room, and soon it'll be automatic. I promise!
Also, I had a resident with pulmonary fibrosis, and her sats fluctuated a great deal from day to day--on high flow O2 delivered by an oximizer. Pulmonary fibrosis is irreversible, and has a high mortality rate. My resident died less than a year after her diagnosis. When she came to us, she was on 16L of O2 delivered by oximizer. Some days the best we could do was keep her sats at 89-90%. Other days she was as high was 94-95%. It's a miserable disease. We kept her comfortable with ativan and morphine, and she also took a lot of mucomyst. Your pt's deterioration is a sad, but normal course of this terrible condition...it is NOT your fault...her sats were within the range specified as acceptable by the MD. If your preceptor had a reason to question those ranges, she could have called the MD. It was downright mean of your preceptor to suggest that your "inaction" of an acceptable value of 92% caused her downward turn.
Perhaps prompt her to check ABG's by asking about protocols for CO2 retention. In some units, house orders including checking ABG's if the pt. is on a certain amount of O2 or above. She sounds like the kind of preceptor who wouldn't be receptive to you suggesting to have them checked, but if you asked "What is the procedure/protocol for doing...." it might prompt her.
Anyway, as everyone else has already stated, you're doing fine! Your learning, and in nursing, you will continue to learn daily, everytime you go into work. It's an amazing profession that way.
I have to repeat everyone else, it's never, ever acceptable to leave an incontinent pt. in their stool. Their is no acceptable amount to lay in. How horribly uncomfortable! When I was being precepted on a tele/ICU stepdown, we had a pt. who was incontinent of stool 4-5x per shift, and we changed her every single time. We made sure she was repositioned every 2 hours, as was protocol. We made the time because it was part of quality nursing care.
I've seen the results at our subacute/LTC facility when pts. are NOT cared for this way. In one instance, the resident arrived from a cardiac unit. He had fallen at home and broken his shoulder, and when they were going to do the repair, it was discovered he needed a double coronary bypass first. He then developed gall bladder problems. All things said and done, he was a very sick man and spent a month in the hospital. He came to use with skin breakdown on both elbow, both heels, his coccyx, and the back of his head. While their were limitations on how he could be repositioned due to the shoulder injury, this was extreme. The nursing notes we received didn't acknowledge any skin issues. I guess they were "too busy" on that unit too.
Learn to do things the right way, and stand up for yourself and your patients!
First of all, you are a new student!! You are learning - you are supposed to ask questions. I get nervous when new grads don't ask questions!! Second, you need to ask for a new preceptor or look into changing units. Any RN that would intentionally leave a patient laying in stool is lazy and irresponsible. And to blame you, a student, for a patient deteriorating?? That's just crazy!! For a patient with a chronic lung condition such as pulmonary fibrosis, an O2 sat of 92% is pretty good. She sounds like a toxic nurse and you need to get away from her. Lastly, (is lastly a word??) do not quit!! I've seen quite a few nurses start out kind of rocky and end up being some of the most compassionate and competent nurses. Good luck!!
I'm a RPN student, just entering pre-grad. I've been assigned to a step-down ICU (acute respiratory), and I've been having some serious personal identity and self-doubt issues since the commencement of this placement.
I've never been in such an acute setting. And I thought it was what I wanted. I thought I would be up to the task.
But the reality is -- I'm not.
Not only are all of my patients dying or coming close to it, I screw up on the most basic of things (like, ugh, leaving a side-rail down and leaving the room), and it seems as though these screw ups keep happening.
I'm so terrified of doing something wrong that I have to ask clarification from my preceptor all the time, and I can see she is getting annoyed with my constant need for affirmation of the most basic of directives. The nurses keep asking me if I've ever had a placement in a hospital before, which should give you a pretty good understanding of just how idiotic I am.
One of my patients has severe hypoxia and shortness of breath secondary to pulmonary fibrosis and dementia. She was satting at 92% on room air during my shift yesterday. I wrote this down on the vitals flow sheet, and left it because I had read in the physician's orders (or so I thought) that she was to be kept between 88% - 92%. Today we got onto the floor, and she was drowsy, completely out of it, and deteriorating quickly. She was on 2L of 02 via nasal prongs, and satting at 96%. My preceptor was very shocked while we were assessing her, and said that it was because I hadn't informed her that the patient was satting "so low" yesterday, and that was why the patient was deteriorating now. I was ready to throw myself out of the window when I heard that -- it made me want to die, to know that it had been my actions that created this downward shift in her condition.
Also, my preceptor doesn't like how I perform patient care -- she implies that I am slowing her down. Today I changed two patients who had become incontinent of stool and had leaked all over their bedsheets. I had changed them earlier in the shift, and when my preceptor saw what I'd done, she got very angry and told me that, in an acute setting, there was no time for that to be done twice. If I'd already changed them, and the amount of excrement was livable, I was to leave them sitting in it because there were more important things to be done.
This is just a small incidence of the philosphy I have been exposed to on this unit.
I feel this isn't what nursing means to me.
And I feel like it's time to drop out, get an $8 an hour job, and turn my back on this wretchedness once and for all.
I guess I'm just not smart enough to be a nurse.
OK, first of all, most of us have been in your shoes, not feeling confident, and making mistakes. I have a ton that I can share if you'd like...I share my mistakes when I am precepting. NO ONE IS PERFECT. I used to leave everyday thanking God no one died. Let me tell you, I got kinda lucky....
As far as the SpO2....HELLO, the ultimate responsibility is on your preceptors shoulders. When you precept someone, you don't just let them loose, and hope they know what they are doing. She should have been checking in on you. And if you are feeling stupid asking questions, then you are not going to ask them, and people will get hurt. I highly doubt that a 92% sat is what nearly killed her...It's not like you ignored an 82% sat, and you came in and she was on a 100% NRB or anything. She was on 2L NC!
OH, and I LOVE the "livable excrement"! HUH?! I'd like her to poop herself, and walk around all day and see if it is "livable". This is how PU occur, and the hospital does not get paid for Tx of hospital acquired PUs!! That is the most ridicuouls thing I have ever heard!
How long have you been there now? Try to give it some time...if it's too stressful for you, try to get a different preceptor, or maybe you need some Med Surg first? But give it some time.
You've gotten a lot of great responses, but there's one thought I'd like to add. Not only will you continue to make mistakes as a nursing student, but you will make mistakes as a new nurse, and then as a not-so-new nurse. We are only human, and human beings are fallible. Of course we should do everything in our power to eliminate mistakes, but sometimes they still happen. The key is to learn from our mistakes, and to be sure not to make the same mistake again.
I am a brand new pediatric nurse, working in my first nursing job, with only 4.5 months of experience so far. My biggest mistake so far was a badly infiltrated IV that I didn't catch until the skin on the pt's arm had become hard and bruised. This was a 9 month old baby, and I cannot tell you how horrible I felt. I had to write myself up, and was pretty badly shaken by the experience. However, all of the other nurses on my unit told me that most or all of them had had at least one badly infiltrated IV. The nurse who precepted me as a new grad had had one of the worst, but had since gone on to become that hyper-efficient hyper-competent nurse that all the other nurses try to emulate.
Since then I have been very vigilant about checking running IVs frequently -- I was already doing this, but check them even more often now. I haven't had any more infiltrated IVs get away from me -- I now catch them as soon as they're starting to go bad -- I sometimes catch ones that day shift has missed (I work PMs).
The scary thing about nursing is that mistakes do have such potentially serious consequences. However, if and when you make a mistake you have to 1) own up to it (report yourself if necessary) and 2) think about what you can do to avoid making that same mistake again.
Having said that, the only real "mistake" you made was forgetting to put the bedrail up -- a mistake that we've all made. As others suggest, you can reduce the chances of making this mistake again by developing a "leaving-the-patient's-room" routine --eventually it will become automatic, but don't beat yourself up until then. Not pointing out an O2 sat of 92% for a pt's whose parameters were 88 to 92% is not a mistake, and changing a pt rather than leaving them in their own stool is not a mistake.
In fact, here's another word of advice. Don't assume that just because another nurse is experienced and you're not, that she must be right and you must be wrong. Trust your own instincts, and learn to stand up for what you believe is right. Like changing your pts rather than leaving them lying in their own feces. Your instinct was right and your preceptor was wrong. Period.
And like most others have said, get a new preceptor if you can!
Specializes in trauma, ortho, burns, plastic surgery.
All of you need a supportative environment. A good nurse become good or bad not ONLY about her skills but most about THE ENVIRONMENT where she works.
You need a good environment a balanced perceptor, a good communication with. I am so sure that you are not as bad as you fell in your heart now, just you need time to adjust, and nurses often they don't have time or patience, or both of them ,looool, and the new ones often they wants to prove them self to soon, and forgot to listen.
ITA with the other posters...we have all made some mistakes.
The biggest mistake here, though, is the person "precepting" you is a preceptor!
I do nutrition support, and a big part of my job is placing post pyloric feeding tubes. We have 4 team members who do it. If a patient pulls out their tube or it gets clogged, one of us has to replace it. The RN on the floor is not trained to place them. Twice this week, we had patients with clogged tubes. Both times, the RN blamed the student nurse. If the preceptor was precepting properly, it would not have happened, because she would have been there to walk the student through how to administer meds through a feeding tube properly. Chances are, those tubes would have gotten clogged anyway because the "preceptor" was not doing it right either. Just so happened the student nurse was the one that did it and therefore got the blame.
If I was precepting you and watching you perform a task, I would make sure you did it properly. If you didn't, I would stop you. And I certainly wouldn't just turn you loose to do ALL the patient care with no supervision...which unfortunately happened to me more than once in nursing school. 10 bed wing of a med-surg floor...as soon as the student nurses got report (2 of us taking 5 patients each) and they decided we had it under control, the RNs and PCA would LEAVE!!!
Hang in there! You will be just fine, because you recognized that something was not right!!
Bhalpern10
7 Posts
rant:
as a nurse educator and an instructor it seems that you are not being supported by your preceptor. i hear from your post that there is a communication break down between you two. the circumstances with your patient being drowsy can be caused by many factors and there is not enough information for anyone to say what the issues was/is. ie what were the blood gasses is the patient going septic? there are many unanswered questions.
for your preceptor to point an finger at you is unacceptable even if you had part in it. that is not a good learning environment and not supportive of your learning. your preceptor needs to be more tuned into her/your patients and ask question to facilitate your learning needs.
if you have an instructor i would suggest that you talk with her/him about the situation. i would also suggest that you sit with the nurse manage and preceptor write out learning objectives. you need to build up your skills and confidence. with your learning objectives i would suggest taking care of 1-2 patients for a short time and then add more as your skills improve. this will help build your confidence as well.
here is a suggestion to start.
day one
rant will assess patient at....(add time) this assessment will be done with the nurse and will be discussed and compared between the preceptor and preceptee. differences will be talked about and the preceptee will then review the assessment again asking questions during the assessment.
rant will help pass medications at (add time) the medication pass will take no longer than ............. mins depending on the route and number of medication. the nurse will check all medication prior to passing of the meds and verify the route, dose time and reason for administering the medication.
rant will pass meal trays at..... time
you get the picture.. i hope this helps you
this will show the nurse manager, instructor and preceptor that you are engaged with your learning and taking responsibility for your learning