6 months in the ED -- should I "get it" by now?

PewpSmith · Mar 25, 2016

Hey there, ER nurse with 8 years varied experience here (3 different ERs with very different settings)

And unless you're well behind your peers with how many patients you're managing at the same time (for instance, if you only had the 1 septic patient and they are caring for a septic patient and 3 other patients) I don't really see where the rub is with this preceptor and you.

Fluids are important- yes- in a septic patient but antibiotics are key also. I can maybe see if abx were initiated before securing your ABCs but the that wasn't the case. And before someone argues that Circulation wasn't secure so fluids were more important- those vital signs provided looked pretty stable to me. Your preceptor seems to suggest that you're treating septic shock and not simple sepsis-- while I can't say at all what the actual presentation of your patient suggested because I have such a small picture, I don't think your patient was critical.

Core Measure initiatives place staring abx and fluids both before 3 hours.

Also.... I don't give meds without a doctor order. There are standing orders in some facilities I've worked at but those were common sense type things with pretty strict guidelines as to when you could give various things.... But to gather meds you think you might need on all your patients seems like a poor use of time since doctors rarely order exactly what we think they will and you'll end up back at the pyxis to return meds or give more....

That being said-- if you have a patient crashing then YES pull the RSI meds and whatnot.

I think that as long as you're on par with quantity of patients you're caring for as compared to your peers then you're fine. I think the quality of your care is fine and will improve with time.

Lev, MSN, RN, NP · Mar 25, 2016

To me, it does sound like you can be ready in three months. Many new grads struggle with seeing the bigger picture. It comes with practice.

You don't strike me as an entitled special snowflake. For one, you are not blaming your preceptor. What is your preceptor's teaching style? Maybe you need a new preceptor?

One thing that stuck me is that you start IVs and start labs before the provider sees the patient. This is a task that you can be delegating once you feel like you know how to put in IVs. Delegating tasks leaves you time to focus on the bigger picture.

In general, patients getting a sepsis workup should have more than one line. If your preceptor says to hold off on the second line of the patient she deemed stable, I would go along with that. Some patients come in looking really bad but stabilize in the ER. Also, the earlier you get the antibiotics in the better. For a patient in full blown septic shock, we run all the antibiotics in together (through separate lines or the compatible ones together). Those patients need 5 liters of fluid and then pressors if the MAP is still low. If I patient is getting fluid boluses especially those with low BPs, I would not run antibiotics piggyback even if ordered as such. Most of the time, I do not run antibiotics IVPB in the ER because 99% of the time they need the fluid now.

As far as hanging fluids without a doctors orders - every facility is different with this - but you can always ask for an order after the fact.

P.S. - I was also told I would drown on my own (wasn't a new grad) - and after my preceptor with a raised voice insulted my practice with one patient in front of another patient, I went to my educator (after calming myself down) and asked for a new preceptor.

Stability in sepsis is not purely vital signs. It is also lactic acid level, CO2 level, WBCs, orientation level etc.

Editorial Team / Moderator · Mar 25, 2016

My preceptor has told me that I am going to drown when I am on my own.

This prediction right here is indicative of a larger problem. Your preceptor has zero confidence in you, and whether or not it is warranted, there it is. Is there any way you can work with some other nurses besides your actual preceptor? You should also have an away-from-the-ED sitdown meeting with your preceptor and educator ASAP and come up with a measurable performance improvement plan with concrete milestones. Good luck!

Anna Flaxis, BSN, RN · Mar 25, 2016

Have you only had the one preceptor this whole time?

almost_nurse · Mar 25, 2016

I haven't graduated yet but I did have a similar experience as a clinic assistant working with NPs at my current job. I struggled with the same question, and got some good advice here. First, I think stress make it difficult to "see the big picture". When you think you're doing a bad job, it (unfortunately) often translates into doing a bad job, because you are distracted. So take a deep breath.

Second, I would make an effort to keep a journal. Write down what went well and what didn't after each shift. Notice if there's a pattern. For me, for example, it was anticipating when NPs wanted a pregnancy test on their patients. I realized it was better to be over-prepared than under-prepared, so I started getting urine samples from every patient until I had a good handle NP preference.

Realize that everyone does things a little bit differently, and recognize when it's someone's preference versus a real error. If two people told you two different things, they may both be right--no need to punish yourself. Just observe that everyone does things differently, and sometimes there will be discrepancies (as you described with hanging fluids on two different patients). Sometimes you just have to say, "okay" and file it away that your preceptor/another educator does things differently than what you have learned.

Is it possible to speak with the other new graduates and find out what works well for them? They may be able to share some strategies with you.

Your post makes it sound like you are very thoughtful and observant. Hang in there. Sometimes it just takes time for everything to come together.

dee789 · Mar 26, 2016

Thanks for the advice everyone, I appreciate it. I am managing the same number of patients as the other orientees -- we officially cap at 8, but staffing has improved a lot since I started and I haven't had more than 5-6 patients at once in a long time. On that particular day I had the septic patient and 3-4 others.

Unfortunately in my facility we don't delegate IV starts, so I have to do all my own IVs. I do however need to improve at delegating as I try to do as much as I can myself and delegating more would probably help me to be less overwhelmed.

I have worked primarily with the one preceptor, but I have had days here and there with other nurses. I haven't had any negative feedback from anyone else except for one nurse who told me I need a "sense of urgency" after I hesitated before drawing up Zofran and hanging fluids on a vomiting patient. It wasn't that I was intentionally moving slowly, I just feel that it still takes me a minute to "know what to do" in a given situation and isn't automatic yet. The rest of the feedback I have gotten from other nurses has been positive or neutral, leading me to believe I am more or less in line with the other new grads. But none of the other nurses know me as well or have worked with me nearly as much as my main preceptor.

I am working with a different nurse this coming Sunday, and have worked with her a number of times as well in the pediatric section of our ED. I plan to ask her for some feedback about how she thinks I am doing so that I can have another perspective. I am only working one more week with my main preceptor and then am switching to a different shift and a different nurse, so I am hoping that may also improve things.

Thank you all again, makes me feel a bit better. I feel that my preceptor expects me to be as good of a nurse as she is at this point and I just don't know if that is realistic. To me, I believe I will continue learning even after orientation is over and that I won't be "fully formed" by the time I come off but safe to practice on my own. Not sure if that is realistic.

Susie2310 · Mar 26, 2016

And before someone argues that Circulation wasn't secure so fluids were more important-those vital signs provided lookedpretty stable to me. Your preceptor seems to suggest that you're treating septic shock and not simple sepsis-- while I can't say at all what the actual presentation of your patient suggested because I have such a small picture, I don't think your patient was critical.

This is incorrect. Depending on the patient's usual blood pressure, 140/70 may be high for them, and BP elevation would not be unusual in the early stages of sepsis. The patient was tachycardic (HR around 112), and had a fever of 100.6, both of which are not uncommon in the early stages of sepsis. Elderly adults and patients who are taking beta blockers may not mount a tachycardic response, and elderly patients may even have a subnormal temperature or normal temperature but may quickly progress from sepsis to severe sepsis and septic shock, as may other patients. The OP's preceptor was correct in his/her response; this was an urgent situation even though the patient wasn't in septic shock.

PewpSmith · Mar 26, 2016

Agree to disagree? You make a lot of assumptions (their usual bp, beta use, being elderly or not) to say it was incorrect but any sepsis patient can go down the tubes fairly quickly. Also, many/most febrile pts I've had are tachy to a degree regardless of cause. Mainly what I was saying was most of the picture she painted was one of an urgent but not "Intubate and Central Line ASAP" critical.

Susie2310 · Mar 26, 2016

Agree to disagree? You make a lot of assumptions (their usual bp, beta use, being elderly or not) to say it was incorrect but any sepsis patient can go down the tubes fairly quickly. Also, many/most febrile pts I've had are tachy to a degree regardless of cause. Mainly what I was saying was most of the picture she painted was one of an urgent but not "Intubate and Central Line ASAP" critical.

You made the statement that "those vital signs provided looked pretty stable to me" and suggested that the OP's preceptor was overeacting: "your preceptor seems to think that you're treating septic shock and not simple sepsis." The OP's preceptor wanted the patient to receive the IV fluids, and chided the OP for hanging the antibiotic IV piggyback which stopped the IV fluids running. The OP's preceptor didn't mention anything about intubation and central lines.

I gave examples of elderly patients and patients on beta-blockers. Of course we don't know the age, medical history or medications that the OP's patient was taking. My point was that sepsis is not something to take lightly for any patient.

PewpSmith · Mar 26, 2016

You're absolutely right-- it is serious for sure. I guess my intent was to make OP feel less grief about the order in which she chose to do things because it looked to me like her patient was urgent and could receive abx as piggyback with no consequence to her patient as opposed to critical and in need of aggressive fluid resuscitation. Again- agree to disagree but I think the OP can breathe easier knowing that there are 2 ways to skin a cat and 2 nurses can look at the same patient and order their care slightly differently and the outcome for the patient will still be ideal because in this scenario I doubt that the fluids being on hold for the piggy back will cause any harm. (Again can't say for sure because neither of us can see the patient in question).

Susie2310 · Mar 26, 2016

You're absolutely right-- it is serious for sure. I guess my intent was to make OP feel less grief about the order in which she chose to do things because it looked to me like her patient was urgent and could receive abx as piggyback with no consequence to her patient as opposed to critical and in need of aggressive fluid resuscitation. Again- agree to disagree but I think the OP can breathe easier knowing that there are 2 ways to skin a cat and 2 nurses can look at the same patient and order their care slightly differently and the outcome for the patient will still be ideal because in this scenario I doubt that the fluids being on hold for the piggy back will cause any harm. (Again can't say for sure because neither of us can see the patient in question).

The OP's preceptor was mad with the OP because the patient had been there a long time and had not received the ordered fluids, so presumably in this case based on the patient's condition receiving the total ordered IV fluids promptly was a priority.