L&D nurse at my wit's end....

mommalumps · May 16, 2010

clb6885,

I am so sorry that you are working hard (sweating and running a marathon for 12 long hours) and proving yourself as a new nurse worthy of this career. I am about to graduate in July w/ a BSN and I currently work as a Nursing Assistant, although I sweat and run marathons throughout my shift (because I have to move to stay awake and I don't like to gossip or read Mary Claires or Vogue at the Nurse's station). I work as a N.A because I have bills and everytime I apply for a new grad program at the hospital, I get turned down. I get more pts. and less help, as well. The nurses do not know that I am in college 1) because we don't talk unless they need help or I ask about the pts. 2) they don't care and 3) I am "just" a Nursing Assistant. So, I understand that lack of help w/ a sprinkle of disrespect. As a new grad, please take the time out to congratulate yourself on years of hard work and accomplishing something that we "newer" new grads can only dream and pray about: landing a j-o-b as an RN. What helps me is to spend time with your pts. and yourself. Ask questions and use your resourses (nurse manager, *GULP* other nurses) only after you have researched the textbooks on the floor and came to your conclusions. You ARE educated, you ARE worthy!!! Fear will make you into one of the FINEST nurses on your floor because it effects you internally and you WANT to make a difference; PLEASE hold this trait firm to your heart. If you feel that this is not for you, gain the experience and move on, if you choose. Nursing School is a breeze compared to the real world, huh? I hope that I have encouraged you in some small way.

Good Luck to You...

debbiernbsn · May 16, 2010

I think L&D is inherently a very difficult area to work in for several different reasons. 1) if you are a new grad then not only do you have to learn L&D info, but also basic med-surg skills and time-management. 2) we are worrying about not one patient at a time, but two. 3) we are hesitant to ask for help when we could really use it, because then we feel inadequate to handle our assignment. I went through all of this when I first started OB, had only worked a year in ER, straight from nursing school. Only time will help, I used to let other nurses dump on me, until I realized that I wasn't doing my license or my patient any favors! So now I ask for help. I have always said that the nurses that aren't at least a little afraid every shift they work, are the ones that really scare me. A little fear keeps you on your toes. Hopefully time and experience will help you, or perhaps you might look into postpartum. I work it mostly now, do L&D probably once a week and my stress level is much lower!

PetiteOpRN · May 16, 2010

I'm confused as to how this patient was considered asymptomatic. Shock is defined as inadequate tissue perfusion, and hypotension and tachycardia are late symptoms. Change in temperature from hyperthermia to hypothermia is also a very concerning symptom.

What else was going on with the patient that made you/the charge nurse decide she was asymptomatic?

Zookeeper3 · May 17, 2010

i'm confused as to how this patient was considered asymptomatic. shock is defined as inadequate tissue perfusion, and hypotension and tachycardia are late symptoms. change in temperature from hyperthermia to hypothermia is also a very concerning symptom.
what else was going on with the patient that made you/the charge nurse decide she was asymptomatic?

i don't think this is the point of the thread, although i may be mistaken.

op, no matter what discipline you start your career with, it will be very challenging with time management. as your finding, knowing what's normal, what to sit on and monitor just takes experience and time. until you get that under belt, you need to use your resources as you are and know that ultimately it's your call.

never hesitate to ask an experienced nurse to explain "why" they would sit on a patient vrs call the doctor. if your not comfortable with the answer then call. never be concerned with an angry doctor. it's not about them, it's about the patient. sometimes you have to listen to your gut, and right now you and your gut are just learning to communicate:lol2:.

patience, time... and take care of yourself on your days off. i promise this will pass, we've all been through this.

JulieCVICURN, BSN, RN · May 17, 2010

Don't beat yourself up. First of all, except for a couple of things you maybe could have done better, you did fine. I don't work L&D, so I'd guess that sepsis is maybe not that common because most L&D patients are essentially young, healthy women. I'll just start with what you could have done better, keeping in mind that you're still a new grad and I think you did pretty well anyway. The only things I would have done was yes, clarify the Tylenol order and then considered the MAP on the patient and whether or not that warranted some kind of fluid bolus or pressor. But...I am an ICU nurse who deals with sepsis all the time. I wouldn't know the first thing to do with a pregnant woman and I wouldn't expect you to know instinctively how to deal with something outside of your scope either.

Having said that, your mistakes were pretty minor. Giving the Tylenol Q6 hours didn't hurt anything. It didn't make her hypothermic and it didn't make her hypotensive. The patient didn't have any mental status change (as evidenced by your saying that she was asymptomatic) and your charge nurse said that her pressure of 80/40 was ok because she was asymptomatic. I have to tell you, though, that in ICU we would call the physician for persistent hypotension that low unless the patient was known to function at that level normally. I'm surprised that your charge wasn't concerned about that.

As far as the sepsis goes, cultures were already drawn and the patient was on a broad spectrum antibiotic already, so other than ordering fluid boluses or a pressor I don't think the doctor would have changed much.

So in a nutshell, quit beating yourself up about this one. Could it have been done better? Sure, but you didn't do so badly and I assume the outcome was ok otherwise you'd be telling us a story with a different ending, right?

I realize that the point of your post wasn't really whether or not you did anything wrong, but I wanted you to know that you didn't do as badly as you think you did. And you should ABSOLUTELY have gotten better support from your coworkers. It's not safe for the patients and it does both you and the patient a disservice when your coworkers aren't supportive.

The first 6 months of nursing sucks. Then it gets better, little by little. And two years later, you'll look back on your first year and realize you knew just enough to be dangerous, and you'll thank your God that you never killed anyone, and you'll feel competent. Trust me. There are an awful lot of us who sat in the parking lot and had to force ourselves to come back in for another shift, but we made it. You will too.

charley75 · May 17, 2010

Your post made me smile after reading it, I now know I was not the only one to feel this way. I have been a ER nurse for about a year and a half and it was my first nursing job. I had that feeling of dreading to ever go back for at least the first year. I was not only learning how to be a nurse but also how in a very busy ER, I remember when I got my first cardiac arrest I thought I was gonna vomit, I was so nervous. Of course I had a doc with me and others to help but it was my pt and I was the team leader. I work nights so every morning I would lie in bed going over the nights events and every pt I had. We have four patients but often one of those patients are a CCU pt and another a intoxicated psych pt with two others maybe an appy or who knows what. I still feel like I am unable to spend the appropriate amount of time I should be in order to give optimal amount of care. Everything I do is rushed in order to get that pt out and the next one in, I do believe it gets better. Hang in there, your confidence will grow and soon your will find yourself helping other new grads. :)

PegRNBSN · May 18, 2010

What you are feeling is very typical of a new nurse. Labor and delivery is a very challenging place to work. Constant changes in patient status, healthy women usually but critical situations can happen on a moment's notice.

I have a couple of suggestions...

If you are thinking maybe you should update the MD, do it. The consequences of NOT calling can be harmful to the patient. As a charge nurse, I consult with my nurses all the time but I never discourage them from calling the MD unless it is something very very minor. What are the consequences of calling the MD when maybe you didn't need to???? Perhaps the MD will be upset but much better than an adverse patient outcome.

The second suggestion is to have a discussion with the charge nurse and perhaps your manager about your assignments and your perceptions of lack of help, unfairness in assignments. The sooner this is discussed the better. There may be things you aren't seeing, or the charge nurse may need some coaching in changing assignments or encouraging good team attitude and a helpful staff.

You were aware that the hypotension and hypothermia weren't normal.....you had the right instincts. Give yourself a pat on the back for that!!!

Sandwitch883RN · May 21, 2010

Julie CVICURN's post is absolutely correct! We have all struggled. It takes time to become comfortable, knowledgeable and proficient.Trust me, I cried my way to and from work on a few occasions. I feel like in my fourth year of L&D i'm just hitting my stride, so to speak.There is still so much I dont't know! I learn something new all the time. It does help to have supportive coworkers and work in a positive environment. I changed jobs quite a few times before working where i'm at now. It's the best job and has made a world of difference in my happiness at work. Keep in mind, that once you have a year of experience, it will be easy to change to other facilities. I thought about giving up many times, but am glad I stuck it out!

P.S- As an aside, I know this isn't the focus of the thread but I just wanted to mention- IF mom's BP is very low she isn't perfusing well, so neither is the placenta. That means baby isn't getting great oxygenation d/t decreased placental blood flow. I would have called the Doc for that BP. You'll learn with experience to stick to your gut instinct and make the calls you feel that you should. It's your liciense on the line, no one else's.

guiltysins · May 23, 2010

Maybe you can ask for a switch to Mother/Baby or Newborn nursery if you feel that L&D might be too much for you now. Of course those come along with their own problems and it's a little less hectic than L&D but your patient load might increase, but there's less meds and more teaching.

geekgolightly, BSN, RN · Jun 22, 2010

You did all you could considering your experience and your lack of help from the more experienced nurses on the floor.

As an aside, I would have asked for a UA C&S, and BMP to check esp the BUN and creat (flank pain) as well as a lactate. And yes! to the liters of fluid and adding a pressor if necessary after the fluid boluses. For future reference only! I have been working MICU for two years now and sepsis is our main diagnosis.

And consider a new hospital's LD unit. Find the most cohesive LD unit in your area and jump ship because it sounds like poor working conditions!

NurseNora, BSN, RN · Jun 27, 2010

I think you did well. Was the baby monitored all night and did it keep moderate variability and accelerations? If so, she truly was asymptomatic and well perfused. The body does not consider the uterus to be an essential organ, so it is one of the first to have it's circulation decreased when mom is in shock. Watch your epidural patients when the BP takes a dump. Often you will see a flat baseline with lates before you see mom's BP drop. When that happens, we give ephedrine to bring her BP back up. OB is almost the only place that still uses ephedrine, it's a very old drug. However, it's the only one that doesn't cause vasoconstriction in the uterus. Most pressors also consider the uterus to be a nonessential organ.

In pregnant women tachycardia is not as late a symptom as in a normal adult. The hemodynamics of a pregnant woman are different from everyone else's.

What was her antepartum BP? Was she one of those tiny little women that walk around at 95/50? One of the first things I do when I have an odd BP is check the prenatal record from the MDs office to see what they have been running. The one patient I had with septic shock had a BP of 120/70 and I didn't realize that that was hypotensive for her until I was able to see her prenatal and saw that she normally was VERY hypertensive.

When you have two patients and are behind and there are others with none, don't be afraid to ask for help. We worry about getting a reputation for not being able to carry out full load. But everyone needs help sometimes, even old-timers. A patient on MgSO4 is high risk enough that many places require them to have one to one nursing care. You had two patients who were high risk.

One of the things that legal reviewers look for is if you did what a "reasonable" nurse would do. So whenever you consult with another nurse, don't be afraid to chart that the strip, VS, labs, whatever was reviewed by M. Smith RN, Charge Nurse. And don't be afraid to wake the doc up in the middle of the night (I work nights too and understand the reluctance to "bother" the doc for something minor). If he wanted to sleep all night, he wouldn't have gone into OB. When you do call in the middle of the night, be sure you're organized and concise. Use something like an SBAR (situation, background, assesment, recommendation) to organize what you're going to say. Something like:

S- "I'm calling about Mary Jones because I am concerned that her BP and Temp are much lower than they were on admission."

B- "She is a G1P0 at 38 4/7 weeks admitted earlier today for treatment an elevated temp. Her vital signs on admission were..." In a very large busy hospital where the doc may have lots of patients, you might have to give a more detailed background. In a smaller hospital where this is his only patient, this may be enough.

A- "Her VS now are___. When she ambulates to the BR she walks with a steady gait, without dizziness or faintness, she is alert and oriented, FHR is 132 with moderate variability and accelerations." (If the doc said you could take the monitor off so she could sleep, I'd put it on again before calling so I'd have that information as part of my assesment of her status)

R- "I'd like to give her a fluid bolus to see if that brings her pressure up any." or "I'd like you to come in and see her now." or "Do you want to give her pressors? or have someone in on consult" or whatever you think might help. If you have no suggestions (as you gain experience, you'll start having suggestions), you can just ask "Would you like to treat her for this low pressure?" When I was a young nurse, we weren't allowed to give suggestions to the doc, so we tried to tell him what we wanted to do by hinting around. It's wonderful that now, not only are we allowed, we are expected to offer recommendations if we have them. It's much easier than trying to get him to figure out what you want without saying it.

When taking verbal or phone orders, in my hospital, we are expected to sign them as TOR or VOR: Telephone/Verbal Order Repeated. That means we repeat it back to him to be sure we have it right. Some docs don't want to bother with that, they just want to rattle it off quickly and go. But you have to be assertive and insist they listen to you and answer any questions you have. They may say, "Give her Terb." I say, "That's Terbutaline 0.25mg SQ? Is that one time only, or do you want it repeated if she keeps contracting?" I can guarantee that you will never again get an order for Tylenol q6h without asking "PRN or around the clock?" It's sad but true that we learn best from our mistakes. (and yours was truly a minor one) If we're not making some mistakes we're not learning anything or we're not very self aware.

Sorry this is so long. I tend to get wordy.