Instructor reamed me even though nurse said I did right thing..what do you think?

Nurses General Nursing

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This is LONG because I want to give a backstory on my patient so maybe you can see my thought process. :redbeathe

I'm a second semester nursing student on a cardiac tele/step down floor (depends on who you ask :rolleyes: ). One of my patients today was transferred up from the CCU last night. Her history-admitted for NSTEMI, also, HTN, high cholesterol, renal insufficency, and had had a stent placed in her LAD two days prior. She had a hep drip going, her 9 am meds were Plavix, aspirin, acetylcystine and metoprolol.

During AM shift report, the patients nurse and I were getting report from the night nurse. The patient's granddaughter came out and said her grandmother couldn't breathe. I followed the nurses in the room. They asked her if she was anxious. The pt said yes, so they got her some Ativan. you could her the patients wheezing across the room and she was obviosly having problems breathing. Anyway, i finish getting report. I had three patients, she was my first stop to assess because, well, she couldnt breathe!

I heard crackles in her both lower lobes and rml. She aslo had wheezing in her upper. She had thready pulse in all 4 extremties, her 02 sats stayed around 93%, her RR was 18, 90 HR, 112/75. She had a cannula on with 3L of 02 going. She complained she was still a little SOB, but besides that she was "feeling better" By that time her daughter had arrived and said "she must have been anxious, the ativan is helping"

30 min or so later, The CNA ask me to help her off the bedpan. Well lo and behold, there are giant clots of frank blood in her stool. besides the obvious black tarry GI bleed stool, I have never seen that much stool. Her doctor happened to be outside her room, so I told him that the patient has bloody stool. he asked if it was a lot, I told him i thought so. He looked at it himself and said "thats not a lot, but thanks for telling me." :confused: I thought it was a lot...but I also dont have anything to compare it to. The pts vitals were fine at this point, still a little SOB, but her 02 sats were fine and the wheezing had diminished, so I decided to just chcek on her often.

ANYWAY, i go to give her 9 am meds about 20 minutes after the bedpan, her BP was 118/78, her HR was 92. In the 15 minutes I was in there, she deteriorated. I made sure her cannula was on, not kinked, and in her nose, and raised the HOB up. She drank her aceytalcystine, took her oral meds, and the whole time kept complaing of SOB. her wheezing started back up again. then she broke out in tears because she was distraught that she couldnt breathe and she didn't know what was wrong with her. so I left to go get a pulse ox monitor. I was gone all of 1.5 minutes. I put it on her finger and it was 78%. :eek: I waited about 10 seconds to see if it would go up, and it got to 80%. No bueno. So i went and got the nurse. the nurse upped her 02 to 5L, raised the HOB higher than I had it and asked me to retake her bp and we moved her up in bed. The 02 sat got up to 90%, I asked the nurse if it was ok for me to leave since I was gonna be late with my other pts meds. So my nurse stayed and helped the pt.

So 15 minutes later I'm updating my insturctor that pt. She asked if I listened to her lung sounds and counted her respirations after i took her pulse ox. HER O2 SATS were 80%!!! I wasn't going to stand there and count her RR and listen to her lung sounds when the pt looks like death and the pts daughter asks me to get the RN!! My instructor got all melodramatic and used words like "abandonment" and putting your patient in danger. :crying2: I'm a second SEMESTER nursing student taking care of a pt who should have never left the CCU to begin with, I am freaking out because I've never had a pt detiorate so rapidly. My main concern was my patient getting oxygen, so I went and got the more expirenced nurse. ***** Please keep in mind, it takes me 2-3 times as long to get RR and lung sounds because I'm a 'nurse-ling'. you guys might have been able to do it in 30 sec, but it would have taken me 2 minutes.

Well while my instuctor is ripping me a new one, the nurse and doc and charge walk by and apparently my patient is going back down to CCU r/t pulmonary edema. My instructor GLARES at me and says, "see, now she's going down to CCU" Again, ***!!!!! NOT my fault she had a new onset GI bleed that the doc wasn't worried about, and me listening to her lung sounds and taking her RR wouldn't have prevented her from having to be sent down there. Right?

Anyway, when the smoke had cleared, I asked the nurse. She said she was glad I came and got her because the patient had deteriorated so rapidly.

So, LONG STORY short...(not really lol), should I have stood there and taken her RR and listened to lung sounds, or was I right to get the nurse? My instructor made it clear to to listen to lung sounds and get RR . And even othough she is technically right, when you can hear the pt wheezing across the room and you can see that the RR is rapid and labored, and when you pt is going to sh*t, should I really take the time to that? :confused::confused::confused::confused::crying2::crying2:

*p.s. i'm still learning, so any CONSTRUCTIVE :D criticism is welcome"

Specializes in SICU.

You asked for constructive criticism, so here it comes.

Although you are only a student your clinical instructor wants you to practice as if "you are THE nurse" while staying within your scope of practice. It was important that the patients actual nurse to be notified of the deterioration but you did not need to leave the patient in order to do this. You could have 1) called out from the room for help, 2) get the daughter to go get the nurse, telling her you needed to stay with your patient, 3) used the call bell system to call for help and 4) in some places they have buttons on the wall for code blue and another for rapid response which could have been pushed.

As for getting the RR and breath sounds you could have gotten them while looking at the pulse ox number. Even if not a number you should have been able to tell just by looking if the patient was breathing faster or not. You don't have to listen in each lung field but from listening prior you would have been able to say if the patient sounded wetter, tighter etc. Remember, if you had stayed with your patient while help came then you would have time to do this assessment even slowly as a nursing student.

Specializes in CVICU.
You could have 1) called out from the room for help, 2) get the daughter to go get the nurse, telling her you needed to stay with your patient, 3) used the call bell system to call for help and 4) in some places they have buttons on the wall for code blue and another for rapid response which could have been pushed.

You're right. and in my case, hindsight is 20/20 :) The only thing I wouldn't have done was call a code blue/rapid response (overkill, she was still breathing), and the nurse I had is known for not answering her pages. :down::down::down: I could have asked the daughter, and pressed the call light though. Next time i will!!!! And assess RR while waiting for the pulse ox to do its thing. I was a little panick-y and agian, hindsight :p Thanks!!

Specializes in Psych, Med/Surg, LTC.

I think you did fine. The nurse HAD to know so she could call the doc and get the transfer paperwork started. IMO this had to be done ASAP. The pt was clearly in distress and crashing and you noticed that. I don't see what knowing the exact respirations would have helped in this situation. She was bleeding, wheezing, and SOB. The nurse HAD to know. I bet you would have gotten in trouble if you didn't tell the nurse fast enough. :confused: But like a previous poster said, do not argue with the instructor. You will not win. You will make it worse. :uhoh3:

Specializes in LTC, Subacute Rehab.

Pt needed assessed by somebody experienced. You did the right thing.

I think UKstudent hit the nail on the head with the following statement "Although you are only a student your clinical instructor wants you to practice as if "you are THE nurse" while staying within your scope of practice."

I can agree with your instructors annoyance but think of the situation in terms of what physical assessments / questions to the patient/ critical thinking and triage think patient stablization and transfer processes you missed because you were tending to a skill which in your last day of clinicals you probably have under your belt. The annoyance is less about what you did than what quality clinical experiance that you could have learned from that you missed.

I say good job OP, and second semester? :smokin:

I agree with "the be careful with that instructor" posts.

It's quite possible that she almost pee'd in her pants when she found out that your patient became emergent :yeah: ... and to cover for her nervousness and look like she was "in control" of the situation (NOT) she made sure she did what I call a "in the hall job" on you to show everybody who is in charge... (NOT).

Specializes in CVICU.
can agree with your instructors annoyance but think of the situation in terms of what physical assessments / questions to the patient/ critical thinking and triage think patient stablization and transfer processes you missed because you were tending to a skill which in your last day of clinicals you probably have under your belt. The annoyance is less about what you did than what quality clinical experiance that you could have learned from that you missed

I do know how to do RR and lung sounds, and i should have counted her RR while her pulse ox was doing it's thing. :smackingf But to be honest, besides doing all that i did, (rasing HOB, make sure 02 is on etc), there was nothing else i could have done without getting the primary nurse. My patient needed more help than I could have safely provided. In hindsight, I wouldn't have left the patient.

Besides what I listed above, what should I have done differently? :)

I say good job OP, and second semester? :smokin:

I agree with "the be careful with that instructor" posts.

It's quite possible that she almost pee'd in her pants when she found out that your patient became emergent :yeah: ... and to cover for her nervousness and look like she was "in control" of the situation (NOT) she made sure she did what I call a "in the hall job" on you to show everybody who is in charge... (NOT).

This is exactly what I thought.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I think you did great. IMO, you seem to really have your sh*t together for a 2nd semester student, and I would have no problems with you taking care of me once you're an RN.

Try to blow it off, and I agree with someone else who said to lay low and hopefully the instructor will find someone else to pick on.

Specializes in CVICU.

You actually did well. Others have pointed out the med thing - even a mean instructor has got to recognize that staying with a patient in respiratory distress will override getting meds out on time. Believe me, if you leave that patient to go give meds you'll have a lawsuit on your hands if she suffers consequences because of it.

It would not have been out of line to call a rapid response on her. I don't know if students are allowed to do that.

I work ICU, so what we would have done (and we have more autonomy to order stuff than many units) is to check the sats (which is on our monitor all the time anyway) listen to the lungs, order ABG's, and H&H and a CXR, check the foley for output, give ativan if ordered and if lasix is ordered, we'll give that too, even if it's not time for that particular dose. While the primary nurse stays with the patient, the rest of us are paging whatever docs she needs to get ahold of and drawing up whatever meds she asks for. We would also immediately switch her from a nasal cannula to a non-rebreather, even if she's a COPD'er. I know that goes against nursing school and you hear all the time about being careful about over oxygenating a COPD'er, but in a case like this it's a fairly safe bet that you aren't going to overload her on O2.

I'm on the same track as the others with not rocking your instructor's boat. Just chalk it up to experience and let your instructor think you're in agreement with her on what you did "wrong".

And really, kudos to you for not completely freaking out in that situation. I'm not sure how I'd have handled it as a student.

Specializes in CTICU.

My first thought was use the call bell/emergency button to get the nurse. Although she was still breathing, it IS an emergency anytime someone is that hypoxic and struggling to breathe. You don't leave them alone, and it's better to overreact than underreact. I also would have asked if someone else could attend to other pts meds while I took care of this patient.

The other glaring thing I saw, which you might want to consider next time, is don't EVER give a pt who is having breathing difficulty stuff to drink.

Specializes in LTC, wound care.

You are getting good advice. Lie low, etc etc. Just get through this and get to the other side. I'm sorry that she wasn't more supportive and encouraging even if she did think you should have done something else.

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