Maybe I shouldn't be an ICU nurse - long

[bethem]

I am a second year RN (i.e. this is my second year out of uni) who has just started in ICU in Feb. I've just finished a night shift. I had the only tubed patient in our little six-bed unit. All was going well, I had everything done and decided to draw up extra syringes for the infusions of levophed and Actrapid insulin.

I had finished checking my patient at 0600 - did the obs, checked her soft restraints were in place and were not too tight and checked that she was comfortable. I stepped out of her cubicle and asked the charge nurse to check my drugs. He was sitting at the station, not six feet from where I stood. I went over to him and he signed my drugs; as he was doing that, the ICU tech said "Oh, she's got her tube out". Sure enough, she'd self-extubated. It turned out OK, no need to reintubate; she is doing well on non-invasive ventilation (BiPAP).

The point is, I feel like this is my fault. I shouldn't have turned my back on her, no matter how well she was restrained or how good she was at 0600.

Add that to the recent mistake I made, when I gave 15mg diazepam IV instead of PO due to a miscommunication about the order, and the additional knowledge deficit I had that almost made me miss someone going in to APO, and I feel like an idiot.

I really like ICU nursing, it's my 'thing'. I don't know if I should be doing it, though; the mistakes I am making are such boneheaded things and could easily KILL someone. I am trying so hard to learn everything I can - I know I will never know everything, but I just want to avoid making these dumb errors. I try to remind myself that I am new to ICU nursing and that no one has died yet due to my idiocy, but I really struggle with the potential consequences of my actions (or inaction). I know experience will help, but I wish I didn't have to do these stupid things while getting experience!

Does it get better? Do you think this is normal for a new ICU RN (both the mistakes and the fear)?

[ghillbert, MSN, NP]

The trick is to be safe while learning. If you have issues with medication, get someone to check all your meds until you're more experienced.. etc.

It's great that you can identify your knowledge deficits. Half of being successful in critical care is knowing your limitations, and being self-directed to learn more and gain new skills. You have that. Now you just need time to join the dots, so to speak. Try not to be too hard on yourself - night shift is hard, and you're a new RN and new ICU nurse. You're not meant to know everything yet.

PS: Re the patient who self-extubated: I bet that never happens to you again! Why did she have restraints on? How did she extubate with restraints on?

[bethem]

PS: Re the patient who self-extubated: I bet that never happens to you again! Why did she have restraints on? How did she extubate with restraints on?

Thanks for replying. I do tend to be quite hard on myself and focus on the things I do wrong, ignoring the things I do well. I'll try to be a bit gentler with myself.

The restraints were on because she had been moving her arms the day before - not close to the tube, but moving enough to make us nervous. Our restraints laws seem to be a bit more lenient than US laws.

Despite being too weak all night to squeeze my hands or give an effective cough, this woman managed to lift her head off the pillow, fold herself almost in half to bring her head to her restrained hands and gave the tube a final yank. She really didn't want it in! My boss was telling me about a man who was fully restrained, trussed up like a turkey, and who managed to extubate himself with his tongue! I guess they find a way if they're that determined!

[night_owl_504]

im in the same boat as you, one year into the CCU as a new grad. i feel the same exact way, and made stupid stupid mistakes just as you. as stated before i learned to know my limits and i dont hesitate to ask. it seems to me that i am doing a lot of the tough things right and just making basic mistakes. however whenever i do make a mistake i make sure it never happens again, so i guess thats why it happens.... to learn.

[XB9S, BSN, MSN, EdD, RN, APN]

I always found that throughout the 10 year plus I worked in critical care there was always some patient that made me wonder if I was capable of doing the job. I think it's just the nature of ICU,

Drug error happen, no matter where you work and as long as you learn from it and don't make the same error again.

Patients self extubate, sometimes no matter what you do they manage it, I have had a patient manage to extubate himself with myself and 2 other nurses at the bedside, it happens.

Make sure your safe, do everything you can to reduce the risk and keep your patient safe, learn from the experiences and try not to be too hard on yourself.

[RN1982]

I always restrain my intubated patients, whether or not they are sedated. I'm not going to risk the patient being able to pull that tube out. We don't do trial releases either. Anyhow, don't be hard on yourself.

[akemi27]

Commenting on the OP - you shouldn't be too hard on yourself, esp. since the pt was able to avoid being re-intubated afterwards. Generally, mistakes are going to happen, and bad days (even months maybe? ) are going to happen as well. As long, as you approach your every shift as careful and thorough as if it was your first, that's all you can pretty much do...Wait til one of your pts cough up the tube or blow the cuff, or...you get the picture!

[suanna]

In an ICU you frequently can't be in your patients room and at thier bedside every second. It's common to have 2 or 3 tubed patients and lacking unusual anatomy you can only watch one at a time. Even with good care and secure restraints you are going to have a self extubation every now and then- don't sweat it unless it happens to you frequently. Make sure you tie your restraints securely, and learn to be aware of the "sounds of trouble"- Most patients trying to self extubate will ring off a "leads off" alarm, or "unable to analyse" due to artifact. Most of the time the restraints are just there to slow them down enough so you can get to thier hands before thier hands get to thier ETT. My mother was intubated 5 times and never once was weaned and extubated by the staff. She always took care of that herself, and flew every time.

[diosadelsol, ADN, BSN, MSN, RN, APRN, CRNA]

Self-extubations are going to happen whether you like it or not. Some pts are Houdinis, plain and simple. I had a pt that extubated herself twice - the first time she folded herself in half, as you described, while restrained and the second time she tongued it out. She, however, couldn't fly without the tube.

I had a seasoned RN give me some good advice (it may be something helpful or not): after you reposition your pt or pull them up, raise the head of the bed to the position you want them and then tie the restraints. If you tie the restraints and then raise the head they will have slack they didn't when you initially tied the restraint and it may be easier for them to fold over and reach the ETT. Just my !

[NeosynephRN]

Hey it happens. We restrain all our vented patients also, unless we KNOW that they will not grab the tube, we had one just recently, not sedated completly A/O never tried for the tube. They can really contort themselves if they want that tube out bad enough. We are not 1:1 because of a vent, so I have to go see my other patient at some point. Do not be too rough on yourself, I am just finishing my first year in ICU..and I wonder if I should do it somedays too.

[ghillbert, MSN, NP]

Wow, I can't believe how many people electively use physical restraints on tubed patients! I would never restrain a patient unless they've had a near-extubation. I've never had a patient self-extubate. I just can't see how with close supervision (intubated patient at 1:1 nursing) you need to restrain people so often.

[Diary/Dairy, RN]

Thanks for replying. I do tend to be quite hard on myself and focus on the things I do wrong, ignoring the things I do well. I'll try to be a bit gentler with myself.

The restraints were on because she had been moving her arms the day before - not close to the tube, but moving enough to make us nervous. Our restraints laws seem to be a bit more lenient than US laws.

Despite being too weak all night to squeeze my hands or give an effective cough, this woman managed to lift her head off the pillow, fold herself almost in half to bring her head to her restrained hands and gave the tube a final yank. She really didn't want it in! My boss was telling me about a man who was fully restrained, trussed up like a turkey, and who managed to extubate himself with his tongue! I guess they find a way if they're that determined!

I had the exact same thing happen to me! That lady was in her 80's and she did it so fast, WHILE I WAS STANDING IN THE ROOM! I never knew little old ladies could be so flexible when they were determined!