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)?
Specializes in Trauma ICU, Surgical ICU, Medical ICU.
I have never had a vented patient be one to one -
One ICU I worked at they paired CVVH with another vented patients - that was too much.
If pts are adequately sedated and restrained you wont have a problem, on our floor--16 bed unit almost ALL pts are intubated...VERY sick people! I often get CVVHD pts with another vented pt. It makes me angry when pts arent sedated enough (unless being weaned). However, most of our pts wouldnt fly if they self extubated. I can say I've only seen it happen once since I started (only 1 yr exp though).
"Adequate sedation and restraints" sometimes just don't cut it. When you have a determined pt on 100mcg/kg/min of Propfol, weighs 400+lbs, and has a head injury, keeping them sedated may not be possible. And in my experience the whole Morphine/Ativan combo isn't worth the time it takes to get the bottles from pharmacy.
Spend a couple more years in ICU and you'll see a few more self-extubations - but don't tell your co-workers that they didn't have their pts adequately restrained or sedated, you won't have too many friends.
"Adequate sedation and restraints" sometimes just don't cut it. When you have a determined pt on 100mcg/kg/min of Propfol, weighs 400+lbs, and has a head injury, keeping them sedated may not be possible. And in my experience the whole Morphine/Ativan combo isn't worth the time it takes to get the bottles from pharmacy.
Spend a couple more years in ICU and you'll see a few more self-extubations - but don't tell your co-workers that they didn't have their pts adequately restrained or sedated, you won't have too many friends.
I'm not sure who you're addressing yourself to, but I've never had a patient self-extubate, and I started in ICU more than 10 years ago. I don't think it's a function of experience.
Your right, Ghillbert, its not a function of experience. As you've posted before you're vented pts are 1:1 - I wouldn't expect to have any self-extubations either if I could watch my pts that closely. However, that's a luxury I don't have all the time. And I'm sure you've read the posts in this thread regarding the nurses being at the bedside when the pt pulls out the tube. Sometimes it unavoidable, that's what I'm saying and I'm addressing it to whoever thinks that any pt can be kept from self-extubation.
Hi Bethem! Don't feel like a patient extubating themselves was your fault. I have been on the unit as a RN for a year and worked previously an extern for 2 years during school. Some patients are like Hoodini's --they can tongue their tubes out, chew on them and find ALL kinds of ways to get it out. Why someone on here would ask you why a pt was restrained is beyond me. It is releveant why they are used. Don't worry about it and we are only human as well. Being an ICU RN is challenging but rewarding. Hang in there!
:DI have been a MICU nurse for 4years and I can tell you that your pt will extubate themselves even if they have restraints on. Dont be hard on yourself. You have only been a nurse for 2 years, it is a learning curve everyday. Many pts can bite the tube, tounge it out or my favorite is to slump down in bed an mange to pull it out. And dont forget that sometimes it is not secured very well. I have worked in both teaching and non teaching hospitals. Drs make mistakes, nurses make mistakes, respitory make mistakes. The point is you are human, remember to relax, take one order at time. And if you are in code do not panic, the pt is already dead, so anything that you do will not make them more dead. The point is just remember to treat the pt not the monitior and one order at time. And you will be just fine. Hang in there it does get better.
I feel a lot better lately. Today the nurse next to me had 2 patients (we have a 6 bed ICU, and we didn't have ONE intubated patient all day yesterday and today!), while I only had 1, so I was keeping an eye on one of her patients as well.
The patient was having multiple seizures which required IV midazolam to abort. I have never seen a seizure and didn't really know what I was supposed to do when she started to seize. Obviously something kicked in, though, cause I ran to the pt before I even realised and turned her into the recovery position, calmly calling for the doc at the same time, then grabbed the midaz without being prompted while the doc guarded her airway. By the end of the shift, the poor pt had had seven seizures, so I could recognise the early warning signs and get midaz into her before she got too into the seizure. I know this is a little thing, but it makes me feel better! I guess I am learning something/have some critical thinking skills (or, you know, common sense) without realising it.
I think I might just be able to do this, as long as there are always lovely people around to help and mop up my tears!
Specializes in All critical care areas except NICU.
Bless your heart! It's perfectly normal! Don't beat yourself up! For the first few years in ICU after school I just knew I was going to kill somebody because I felt I had no clue what I was doing but 13 years later I'm still there! Feeling better about my knowledge but never knowing everything! Comfort will come with time. Give yourself at least 2 years! It's a lot to learn in a very stressful area and ICU nurses can be harsh! Take a deep breath and keep on going! You'll be fine!
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PiPhi2004
299 Posts
If pts are adequately sedated and restrained you wont have a problem, on our floor--16 bed unit almost ALL pts are intubated...VERY sick people! I often get CVVHD pts with another vented pt. It makes me angry when pts arent sedated enough (unless being weaned). However, most of our pts wouldnt fly if they self extubated. I can say I've only seen it happen once since I started (only 1 yr exp though).