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My first 100 days on the job: Week 4

Has 5 years experience. Specializes in Cardiac.

Background: In June 2015 I relocated 1,000 miles from home to the East Coast after accepting a New Grad Nurse Resident position in the ICU. I want to post my story here as I begin this journey to get some feedback, share what I've learned, ask for support, and to help me reflect and grow as a new nurse.

Day 7 & 8

I had a weird week.

My pt was a 50-something homeless female with suspected ascending paralysis of unknown cause. I hate to say it but she really, really frustrated me. She was needy and showed no interest in leaving the hospital. She refused most tests, treatments, and all medications (except pain meds, and only the good kind, of course). She constantly rang her bell.... "I want to be turned." "I can't find my phone." "Could you bring me more ice chips?" "I am cold, could you grab me more blankets?" "I'm too hot now." "I need more pillows." "I want my hair up."

I felt like I neglected my other patients this day. This lady sucked up my time and energy. I became so angry and annoyed. I was more of a maid than a nurse. Around 2pm I realized that I hadn't peed, sat down, eaten / drank anything, or completed charting ANY assessments. I found myself having to deep breathe and check myself, especially when I would try to exit her room and she'd say things like: "No wait, don't leave. I want something else." Pause. Waiting. "Um.... Can you sit my bed up? Oh! And put my socks back on... And turn me on my side again."

And then a few minutes later... RING RING RING. She was still uncomfortable. She wanted her purse back on her table. She wanted a different room, she didn't like this one :banghead:

She was on Q1 neuro checks, and she really tripped me up on that. She'd tell me that she had double vision, and when I held fingers up, she'd be able to count them correctly. She could feel sensation on her right leg and left arm - and then it would switch an hour later. She'd ask if she was in her friend's house. Then a few minutes later I'd sneek in some assessment questions, which she'd answered perfectly. A&O x 4, able to connect ideas, follow commands, ect. Also, when it came into question whether or not she'd get her pain meds due to feeling "weird," she'd say "Oh I'm fine now, just in pain."

I always responded promptly to her call light. I always gave her the pain meds she wanted. I treated her with calmness and friendliness. But I couldn't wait to give report... The oncoming night nurse was not happy about getting this patient back.

On Day 8 I was caring for two new patients (a STEMI and NSTEMI) when a nurse comes up to me asking if I wanted to watch a lumbar puncture done on the neuro lady I had on Day 7. I asked if she was accepting treatments/ tests now.

"Not exactly. But she doesn't have a choice now and her family gave consent."

She had been intubated overnight. They think the paralysis had ascended up to her diaphragm. She still didn't have a dx, but it was discovered that she had a family hx of neuro problems. When I entered the room I couldn't believe it. She went from having nothing to having a Foley, rectal tube, ETT, multiple lines, and was completely knocked out. It was so strange... all of these tubes coming out of her, her eyes half open, staring at me as we turned and adjusted her body, totally limp. The way everyone moving her body around made me think of a rag doll.

It didn't feel real.

Sometimes I feel guilty for feeling so angry with her. She wanted conversation, a friendly face and comfort for once, that's it. I mean where was her family who gave the history and consent for the lumbar puncture? Where was the friend who's house she was referring to? Was she actually manipulating me? What was real? What was fake? Is she going to get through this okay? Is she still going to be alive when I go back to work next week? If so, what's next for her?

It is so strange sometimes, if you take a step back, and really think about and reflect on what nurses experience each day, and the questions that run through our heads.

I feel like I need to lighten the mood now after typing up such a serious post... OH! Here's a good one:

My preceptor asked me to call the doctor about a medication and restraints. She knows I hate the phone and calling doctors, and I hesitated, but agreed to try.

I dialed the number. I was nervous. The phone began ringing and then my mind went blank. I didn't know what I was going to say.

I asked my preceptor: "WAIT? What am I saying?!"

Her mind went blank as well. "Just hang up!" she said.

The doctor answered, "Hello?"

I said "Eep!" and hung up... I actually eeped....and hung up on him.... So, so embarrassing.

Things I Learned:

- Even when it really looks like your patient is making everything up... be prepared for it to be real.

- I will never work in a neuro unit.

- Lyme disease can cause heart blocks. A western blot test can confirm Lyme disease.

- In simulation I went through the motions of interpreting rhythms on a monitor, making decisions, giving Epi, cardioverting/ pacing/ defibrillating, which really helped my learning. I have ACLS in a couple weeks. (Also simulation on the job isn't nearly as terrifying as simulation in nursing school).

- Lumbar puncture nursing care includes: assuring that the pt has no cerebral tumor, keeping pt in lateral recumbent position with knees flexed, ensure strict sterile technique, ensure labeling and CORRECT order, keep pt flat for a few hours & encourage fluids to reduce headache (HA might occur no matter what), monitor neuro/VS/admin analgesics.

- STEMI - ST elevation myocardial infarction. More severe of the two types of heart attacks. Shows ST elevation on EKG. My pt treatment plan for the day included receiving multiple stents, integrilin, nitroglycerin.

- NSTEMI - Non-ST elevation myocardial infarction. Less severe. No ST elevation. Pt received nitro and was scheduled to go to the cardiac cath lab that night.

- Nitro drips: used to tx chest pain and high BP. Vasodilator. Can cause drop in BP, headaches (give your pt Tylenol), start with 5mcgs/min, up by 5 every few mins, once you reach 20mcg it can be titrated by 10mcg Q15 mins (we were giving our pt 100mcg/min at one point)

- Post cardiac cath nursing care: assess puncture site for hardening, redness, pain, bleeding (especially after vomiting or when pt is exerting pressure. my pt popped his while urinating and started bleeding everywhere) also check pt for diaphoresis, pallor, VS (variations in BP/ HR), pedal pulses

- Integrilin (eptifibatide) - used for preventing clots after stent placement

Needs Improvement:

- I hate to admit it but I could feel myself wanting to snap at my neuro lady pt at one point.... maybe it was the hunger, thirst, over-filled bladder, being tired, or feeling manipulated, but I know that being close to snapping at a patient is never okay, no matter what. Breathe breathe breathe.

- I really need to get better about looking up medications on my days off. I'll try to look them up quickly before giving but I don't always... Very bad.

Victories:

- I never did lose my composure with my neuro lady, so I'll take it.

- A resident asked me to get a 12-lead EKG on a pt and I couldn't find my preceptor at the time, but I got it just fine on my own!

- I was told that I'm good at taking initiative on doing trying things.

- My NSTEMI pt had very anxious visitors. They constantly stared at the bedside cardiac monitor and became panicky when the numbers changed. I explained what everything meant (BP, HR, O2, MAP, EKG) normal parameters, and assured them that we could see everything from the nurses station and that we would never be far. This really helped them relax. I love teaching!

Question this week:

I need to figure out a graceful way to get out of a needy patient room. Suggestions?

Previous Posts:

The Beginning: https://allnurses.com/general-nursing-discussion/my-first-100-1000287.html

Week 2: https://allnurses.com/general-nursing-discussion/my-first-100-1002031.html

Week 3: https://allnurses.com/general-nursing-discussion/my-first-100-1002529.html

Edited by BeatsPerMinute

I've been looking for your next post!!! This is awesome. Love it!

kidsmom002

Has 15 years experience. Specializes in Postpartum/Lactation/Nursing Education.

I LOVE the part about saying "eep" and hanging up on the doctor! Made me laugh soo hard. Hilarious. Thanks for the humor. :up:

2k15NurseExtern4u, BSN, RN

Specializes in L&D.

This is awesome! It looks like you learned alot of valuable information this week! Good for you! As always, I love reading your posts.

icuRNmaggie, BSN, RN

Has 24 years experience. Specializes in MICU, SICU, CICU.

Just say" is there anything else that you need" and " I have to go do some work. "

At some point you have to say " I have done everything possible to make you comfortable. Take a nap. I will check on you in a half an hour. "

She was a twelve hour patient. Everyone has to take a turn.

It sounds like Guillain Barre, if so, it explains her high anxiety. This patient will teach you a lot.

Edited by icuRNmaggie

BeatsPerMinute, BSN, RN

Has 5 years experience. Specializes in Cardiac.

icuRNMaggie:You were right!! It WAS Guillain Barre! So crazy. And thank you for the tips :)

I have had many less than graceful moments... Tripping, dropping stuff, bumping into people, ducking from the MD I eeped at and hung up on...

Week 5 will be up later today for those interested in following!

icuRNMaggie:You were right!! It WAS Guillain Barre! So crazy. And thank you for the tips :)

I have had many less than graceful moments... Tripping, dropping stuff, bumping into people, ducking from the MD I eeped at and hung up on...

Week 5 will be up later today for those interested in following!

Where is it? Bahaha, saw this post and immediately did a search. ..

BeatsPerMinute, BSN, RN

Has 5 years experience. Specializes in Cardiac.

a little late, but finally got it up! :)

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