I graduated school in december 2009. I started my job in Labor and delivery in Jan 2010. I had 12wks of orientation and have been off orientation since april on the night shift. I have been experiencing so many feelings about my job and I don't know what to do.....
First of all, I still have SO many questions....I ask them, but don't always get the help I need. It seems I am always working harder than others, and have more patients than others. I may have 2 pts, another nurse doesn't have any pts, but doesn't offer to help me when I am behind on charting and running my legs off. I come home most days overwhelmed and wanting to cry. I know people say to leave work at work, but I come home dreading the next time I have to go in. I try to go to sleep, but all I do is play back my shift in my head until I find something I did wrong or "potentially" wrong, then I worry all over again.
For example, last night I had a pt 36.5wks that came in on the shift before mine. c/o right flank pain BP 106/51 temp 101.5, and HR 127. CBC had revealed elevated WBC and low platelets. Ultrasound of abdomen and chest normal. Dr aware of this and had ordered tobramycin and ampicillin and a one time order of demerol/phenergan IVP for pain. results of blood cultures were pending. FHR in 120s-130s with acels and moderate varibility.
At the beginning of my night shift, the dr ordered a repeat CBC and metabolic panel at 0600 the following morning and ordered tylenol q 6hrs. the pt's BPs were 80s/40s all night, but the pt was asymptomatic. My charge nurse was aware of the BPs and said to "let it bump" since the pt was asymptomatic and we'd call the dr when we received the 6am lab results. I continued with the ordered antibiotics all night. At 0600, labs had been drawn but not yet resulted and the pt's temp was 95.4 taken 3 times with 2 thermometers. at 0630, I reported this to oncoming nurse and the oncoming nurse was going to call dr as soon as labs resulted.
I came home worrying about the pt and then it hit me that I wonder if the dr meant for the tylenol to be q6h prn fever? She didn't say that, but I was so busy( I had a mag pt also) I totally didn't clarify the order and it didn't hit me until I got home. I called back up to work 2hrs after I left and talked to the nurse that took over my pt. I told her about the tylenol order and that she may want to clarify the order with the dr. She stated when she called the dr, the dr said the pt was probably septic bc sometimes a low BP and temp can be indicative of sepsis. Her orders were to continue the IV antibiotics until the blood cultures resulted.
I seem to have a hard time knowing when to call the dr, so I run it by my charge nurse. She had told me to let it ride since the pt was asymptomatic.......I have been worrying ever since that I messed up!!!
I hate feeling like this and this is just one example of how I feel normally on an everyday basis......Is this normal or am I not cut out for labor and delivery? I often wonder if I need to find a less stressful job somewhere. Will this get better or do i need to find another job? or am i not cut out for nursing at all????
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.
I absolutely LOVED your post! When I was on orientation I was scared about every little thing I did (like calling the docs) and if I would have read your post I would have felt so much better about things because you explain it in such a positive way and give great suggestions! And clb6885....it does get better and it does get easier. L & D is a specialty that you don't want to get "comfortable" in, because if you are comfortable then you need to move on. You have to stay on your toes and be ready for anything, but NurseNora is right...you make the mistake once and you probably won't make that same mistake ever again.
Valerie RN, BSN
7 Posts
I absolutely LOVED your post! When I was on orientation I was scared about every little thing I did (like calling the docs) and if I would have read your post I would have felt so much better about things because you explain it in such a positive way and give great suggestions! And clb6885....it does get better and it does get easier. L & D is a specialty that you don't want to get "comfortable" in, because if you are comfortable then you need to move on. You have to stay on your toes and be ready for anything, but NurseNora is right...you make the mistake once and you probably won't make that same mistake ever again.