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 Med-Surg.

I think your instructor sounds like a jerk. How could she blame you for the patient going back to CCU? Ridiculous. Absolutely. It was nobody's "fault."

If it were me, I'd have pushed the call light, put up the head of the bed, checked the O2, RR, and lung sounds all while the nurse was on her way. I'm sure she checked all that herself when she got there, right? I mean you're a second semester student. You sound like a very astute one, but I always felt like it was dangerous to let somebody think I knew anymore than any second semester, or third semester, or fourth semester nursing student normally would. We might have a lot of book knowledge, great critical thinking skills, and a ton of common sense, but without experience, we don't know what we don't know and neither do the nurses we are working with - know what we don't know. Had you spent more time playing nurse, you could've cost your patient some critical minutes. I would think your instructor would think patient safety was a little more important than your learning experience.

I agree with everyone who said not to get into a match with your instructor. I wouldn't kiss her behind, either. If that was your last clinical of the semester, hopefully you won't have to see her again. I also agree it wasn't very good judgement to give someone who just came from CCU Ativan for SOB. Sounds like you were in the middle here. Chalk it up to learning not only about your patient and her pathologies, but also about the differing personalities we all have to deal with in this profession.

BTW, I wouldn't have left to do meds. Staying to watch how the situation was handled would've been a great and safe learning experience. :)

You're going to be a great nurse. Keep on keeping on!

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Specializes in Critical Care, Patient Safety.

Just keep your head down and take feedback/criticism from you instructor to get through this clinical rotation.

I do think she said what she said partially to establish control and authority. At the end of the day, I do think you should have stayed with the patient, BUT you did a great job with keeping on top of it and tending to their immediate needs. I'm glad that your nurse preceptor gave you great feedback.

Also keep in mind that some clinical instructors won't be happy no matter what you do and may dispense endless amounts of criticism. Don't take it personally. Just keep your eyes on the prize and move forward. It can be very wearing but remember to focus on the positive and be your own cheerleader. I felt really beat up at the end of every quarter despite getting really good evaluations.

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Specializes in ICU, Telemetry.

First rule of nursing school -- the instructor is always right, ESPECIALLY when she's not.

I've had pt's crash on me as a nurse, and you've got some great advice. You will have MDs act just like your teacher did when their patients crash and you've been telling them all night that the pt's going bad and they've blown you off. Practice your poker face, and document like your life (or license) may depend on it.

The only thing I can think of to add, in addition to focusing on the respiratory stuff is know 3 things when you get a pt on a heparin drip -- know the last PTT, when's the next one due, and what's the setting. You said the person was on plavix, heparin, etc., having bloody stool. I'd have hit the button and called my instructor and the pt's primary nurse for that (with a really strong, "I need help down here NOW"), rather than verbaling the doc -- he's not going to chart he was told, (and will swear up and down "nobody told me...") and I would have asked for a stat coag panel. I read the story and thought was, "I bet the APTT was sky high or the INR was -- GI bleed starting, pt going hypovolemic, beginning of shock, pulmonary edema and you're off to the races."

Scary stuff. Remember how that pt looked and acted, what their coloring was, how they sounded, so next time, you'll recognize "BAD STUFF HAPPENING!" even faster. That's how you get nurses who can enter a room, and they're suddenly yelling for ABGs, coag panels, FSBS, or whatever when as a student you're going, "what the heck are you seeing??"

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Specializes in Cardiology (ITU), Acute Renal/Dialysis.
I think you did great. I also think the bedside nurse dropped the ball. The wheezing should have been addressed immediately. Wheezes are not treated with ativan.. Had the pt had a neb, maybe some lasix it is possible that all the drama could have been avoided. Stay out of that instructors way. You need to kiss butt the rest of the semester. Good Luck

Cant believe Ativan was even condidered especially when you can hear a wheeze. :confused: and considering all other problems!

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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? :)

As a SN you did correctly in calling the RN who is responsible for the patient period thats why your partner RN said you did the right thing.

Given the info you have provided lets work through it. Your instructor may be trying to get you to connect the dots. Your vent seems to be focused on being reamed out/prejudicing the rest of your interactions with this instructor/ blaming the Dr for not really caring about the patient's bleeding and that the patient should not have left the CCU please put all those thoughts aside for a minute and focus on the patient and what you saw.

On a basic subconscious level you knew that something was serously wrong well before the 9am meds... she was "anxious" and SOB you were concerned and checked on her frequently. You have prob researched this patient's history to death prior to taking care of her so things that I would have thought about would be 1: does she have a history of anxiety? 2: If no, did she exhibit any anxiety while in the hospital... If you dont know when you are with the patient ask her... 'have you ever felt like this before'. Rarely in my experiance do people have anxiety to 'panic attack' level for the first time in their life in the hospital they either have a history or something is brewing.

Your assessment showed crackles and thready pulses x4...Did she have edema? How does this compare to her last assessment or a known baseline. How do the VS compare to previous ones. She has a HX of HTN and Renal insufficiency and is getting IVF how does her I+O from the previous shifts total up is her intake ahead of the output... many times the fluid goes to the lungs first. By this time she said that her anxiety was decreased but she still felt SOB the question is Why...

Following the the bedpan event and during your 9am meds she became teary and upset the question is why.. in her case you discovered it with the pulse ox machine number but lets play devils advocate and say you didn't have access to one what information do you have: 1) SOB, 2) Bleeding 3) cognitive change (teary) 4) thready pulses and a boat load of anticlotting medications... heparin, plavix and aspirin I would have called a RR at this point because the patient is either bleeding internally or not getting enough oxygen either way she needs intervention in the unit.

What you missed was what interventions the RN did after you left... what did she tell the patient and the family, how did she utilize peers and UAP's in getting the patient to the unit while managing the other patients on her load. What conversation did she have with the Dr, what questions did s/he ask about the patient. Were their any STAT interventions that happened. How about the transfer report what occured then.

As you said hindsight is always so much clearer and you were freaking out on two levels 1: generally as a student and 2: your patient was tanking. This probably impeded your hearing what your instructer was really saying to you. Her job is to ready you to be a nurse and to help connect the dots. Her statement about the abandonment and putting the patient in jeopardy was probably in terms of IF you were the nurse ultimately responsible for this patient by going and giving the others meds would have been exactly correct. Your instructors have the difficult job of assessing students "fitness" for nursing based on their actions as a student. People respond to stress in different situations I've worked with licensed personel who after many years of being a fabulous nurse the only useful thing they can do in a code is bring the crash cart then get out of the way....as a second semester student you just need to keep looking inside yourself to know how much you can handle.

Now get into your instructors shoes and think about the situation. Based on your interaction with your instructor after the incident from what you reported the only things that you could demonstrate verbally of your assessment of the patient in obvious respiratory distress was an oxygen saturation number... You admitted that know that you didn't count RR and do lung sounds but what other respiratory assessments could you have done quickly in the meantime. When you put the pulse ox on her finger how cool was her hand (temperature can affect pulse ox measurement) was her nailbeds discolored? How about her lips were they discolored? Was she using accessory muscles to breath? Could you hear wheezing while standing next to her? Was she able to speak if so how many words togeather before taking a breath?

Having said all this I DO NOT EXPECT A 2nd SEMESTER STUDENT to be able to connect the dots during a situation such as what this patient had and thus you did the right thing for this patient but I do expect that after the fact you should be able to process through the situation using your critical thinking skills and come up with some assessments and things that you could have done more than mimicking what your instructor told you should have done. Being a student is about learning .... get used to it because you will be a student for the rest of your career. Every day I think about things I could have done sooner, assessment questions I should have asked and responses that could have been different Its the only way I can become a better nurse. Good luck and work hard in the rest of your schooling.

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Specializes in Cardiology (ITU), Acute Renal/Dialysis.
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!!

yeah hindsight is a wonderful thing as is saying what we would do in that situation :rolleyes: however,having been a student nurse myself - maybe some others were born that way! LOL I think you did well & will reflect on this & do better next time. Thats the only way we learn , GOOD LUCK :nurse:

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Specializes in CVICU.

The only thing I can think of to add, in addition to focusing on the respiratory stuff is know 3 things when you get a pt on a heparin drip -- know the last PTT, when's the next one due, and what's the setting. You said the person was on plavix, heparin, etc., having bloody stool. I'd have hit the button and called my instructor and the pt's primary nurse for that (with a really strong, "I need help down here NOW"), rather than verbaling the doc -- he's not going to chart he was told, (and will swear up and down "nobody told me...") and I would have asked for a stat coag panel. I read the story and thought was, "I bet the APTT was sky high or the INR was -- GI bleed starting, pt going hypovolemic, beginning of shock, pulmonary edema and you're off to the races."

PTT was 43, plat was 203, Hgb 8.3 hct 25 and the next PTT was for 12:30. the heparin was, I wanna say 10cc/hr??? I don't remember, and I didn't write it down. I let my instructor and the primary nurse AND the doctor know about the bloody stool when it happened, about 30 minutes before she deteriorated. Trust me, i keep all important parties updated :nurse:

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Specializes in Hospice, ONC, Tele, Med Surg, Endo/Output.

:):)Honey, you have the makings of a great nurse; you knew the pt had AUDIBLE wheezing, anxiety, and dropping oxygen saturations that did improve. Remember, you are a 2nd semester NURSING STUDENT. The instructor who reamed you is a smug, controlling witch/warlock who enjoys making students squirm--she probably has an orgasm each time she sees the crestfallen face of a student that she has emotionally maimed.

Have you ever heard the phrase "nurse's eat their young"? It is true that this cruel behavior is rampant throughout nursing; and all of this will happen again once you are on the nursing floor as a new grad.:eek::crying2::crying2:. You are obviously intelligent, caring, sensitive-:redbeathe:redbeathe-you will do well to remember that some people just can't help making other people miserable--emotionally banish them from your life and smile in their faces.

Karmic retribution is something you can count on in this life. The nurse who is in charge of the patient is the responsible party--not you. And that old hag/hog who reamed you will get their's. YOU DID NOTHING WRONG. :yeah::yeah::yeah::heartbeat:heartbeat:heartbeat

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Specializes in Hospice, ONC, Tele, Med Surg, Endo/Output.
PTT was 43, plat was 203, Hgb 8.3 hct 25 and the next PTT was for 12:30. the heparin was, I wanna say 10cc/hr??? I don't remember, and I didn't write it down. I let my instructor and the primary nurse AND the doctor know about the bloody stool when it happened, about 30 minutes before she deteriorated. Trust me, i keep all important parties updated :nurse:

Hey, nerd2nurse: How the heck is a nursing student supposed to know to do all this?--She is 2nd semester; give her a break.

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Specializes in CVICU.
Hey, nerd2nurse: How the heck is a nursing student supposed to know to do all this?--She is 2nd semester; give her a break.

thanks for having my back, nurwatsr! :yeah:but i did know about the H+H and plats being low/critical when I assesed her that morning. plus she was on heparin, Thats why i was worried with the GI bleeding! and then when I heard crackles in her lungs and SOB, I did think pulmonary edema. i'm only second semester, but I know some basics :D

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Hey, nerd2nurse: How the heck is a nursing student supposed to know to do all this?--She is 2nd semester; give her a break.

The OP asked a community of nurses for a 3rd party situation analysis of a clinical situation. The OP asked for constructive opinions... she mentioned the patient had a heparin drip and active bleeding... While I cant speak for nerd2nurse I will say that even as a second semester student there should be some sort of connection between these two facts even if the correlation between PTT and titration/protocol is well beyond the scope and current educational level.

I am surprised by many comments in this thread that are just supportive pats on the back while they make the OP feel better I dont see how they are useful in the longterm. If the OP just wanted moral support then please put it in your post so that others that will spend time explaining clinical things can find another post.

We are quick to judge the Instructor and blame it on "eating younger nurses" but fail to recognize that the OP was reportedly upset and interpreting the situation as such in her view. There are 3 sides to every story yours, mine and reality.

OP did nothing wrong however did appear to need some assistance determining clinically what could have been done differently or additionally because it was not outlined in the clinical description. Nothing that I have read has been anything but supportive from the other posters. I think it is responses like yours that keep clinically intelligent dialogue (which everyone benefits from) from occuring. Its too bad.

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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!!

i applaud you for handling the situation so well. even if your instructor wanted to help you think like a nurse, she should have at least acknowledged the things that you did do well. injuring the spritit of a student nurse is not the way to ensure that she/he will become a knowledgeable nurse.

i would like to point out though that the fact that a patient is breathing, does not mean that a rapid response would be inappropriate. on the contrary, you do call a rapid reponse in a situation like this, before it deteriorates into a situation where the patient is not breathing, in which case a code would be required. it therefore, in my humble opinion, would not have been overkill to call a rr. i'm a new rn, and i have been taught over and over that anyone (including the patient's family) can initiate a rapid response when the patient "just doesn't look right." meaning, there's a definite change for the worse, but you may not quite be able to put your finger on the exact cause of the problem, or maybe not even quite sure what the problem is. it is way better to call a rr and find that you didn't need to after all, than not to, and find that you needed to have done so.

but all in all, i think you did an excellent job in doing all that you did, and especially in getting the primary nurse involved asap. :yeah::yeah::yeah:

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