Need some tips avoid panicking when pt condition declines/need immediate intervention

~Mi Vida Loca~RN, ASN, RN · Apr 10, 2017

Can you give a little more information, such as what types of situations are happening that you are finding yourself panicking?? What kind of acute care setting are you in?

mugs · Apr 11, 2017

I work on telemetry unit. I had a pt who had 3 beats of vtach I knew it was not emergent situation as the pt was asymptomatic VSS. AAOX3. I called attending at 5 am and wanted orders for lab, attending got upset that I should have called cardiologist. I became nervous and I did not ask her for BMPand Mg lab. Finally l called cardiologist at 6 am and got the orders.I know what to do but I keep asking other nurses even though I know I am doing the right interventions it makes me feel that I am less confident.

AceOfHearts<3 · Apr 11, 2017

It's honestly probably just going to take time and experience working through situations. I started on a tele unit that could get very critical patients. About 8 months in I had a patient who had really declined overnight (I did day shift) from the day before and the on-call provider overnight pretty much did nothing despite the best efforts of the night shift RNs. I immediately got the ball rolling and just started paging provider after provider until I finally got somebody who listened and immediately came to assess the patient. I got the patient transferred up to ICU for major major interventions. I later realized that had it been even a couple months earlier I would have been unsure and needing help/guidance from other nurses on my unit.

3 beats of VT really isn't that bad. We'd make note of a run that short, but probably wouldn't have been paging in the middle of the night unless it was a provider that was awake and at the hospital at that time. I think we called if it was 5 beats or longer. We'd print out strips for their charts of any runs of VT, but it can be normal for some patients to have little runs of VT and it can be exepcted after an MI. We'd be extra vigilant with monitoring and would check labs, but that's all you can really do sometimes.

sallyrnrrt, ADN, RN · Apr 11, 2017

It is usually advice and direction from seasoned nurse

Wuzzie · Apr 11, 2017

You kind of learn by doing. Try jumping in and helping when another nurse's patient is decompensating. Don't hang back. Then when it's over ask questions. Or find a seasoned nurse who's open to teaching and let her know that you're setting a personal goal to get more comfortable in unstable situations. She can guide you. Involve your clinical educator and manager. Offer to do a case presentation on a situation you've been in. There are lotsmofmwaysbtomlearn and likely lots of people who would be more than happy to help.

nutella, MSN, RN · Apr 11, 2017

You might need a more structured approach to "how to" when things are "not ok".

Look at some SBAR forms and adopt one that you like and have that handy for communication with the MD - that way you will go through all the communication steps and it keeps you on track while talking to the MD.

The other thing is to remember priorities.

In teaching hospitals it is a bit easier in my opinion as you call the resident with everything and they are willing and up to the task.

When you work in a community hospital, you may have to struggle with unwillingness. The SBAR format really helps with that one too.

It is ok to ask another nurse for a second opinion but you should not have to ask for everything. Memorize some algorithms so you get more secure.

RNperdiem, RN · Apr 11, 2017

I agree with the other posters.

When things take a turn for the worse, call in your charge nurse or another nurse.

For some reason, I can think perfectly clearly if it is someone else's patient in trouble, but I get way more anxious if it is mine. Anxiety makes it harder to think clearly.

With enough practice and experience it does get easier.

Rocknurse, MSN, APRN, NP · Apr 11, 2017

Make yourself a checklist or spreadsheet that you can carry with you or put on your phone as a guide with all the most common acute problems you might encounter, so that when you're under pressure and can't think you can glance at it and instantly remember the important thing. For example:

Pt is tachycardic:

Are they dry? Have they taken a med that can raise their HR? Are they septic? Are they SOB? Do they have a hx of this? Is their BP ok?

Pt is hypotensive:

Are they bleeding? Have they taken a med like a beta blocker recently? Are they septic? Do they have chest pain? What was their last hematocrit?

The patient has spiked a fever:

Are they septic? What was their last WBC? Has there been a recent culture? Are they tachycardic? Are they SOB? Do they have a wound/recent invasive procedure?

Bascially, find a problem and then write down all the differential diagnoses (most obvious likely reasons) that this is happening. For low BP it could be sepsis, hypovolemia, medication, bleeding etc. Then search for the most obvious tests/interventions for that. If you make it like a grid you can cross reference things. You'll soon get to know the obvious things to look for.

Once you do that you can then write a list of to-do's for each thing. For example:

The patient is bleeding:

Check the H+H. Check the coags. Do they have a recent cross-match. Check BP and HR. Check wound/drain/dressing etc

Then, when you have a declining pat, go through all the questions/points and check you have the answers and then call the doctor and provide the info in an SBAR format for clarification. There are plenty of guides to using SBAR online. Pick one you like.

mugs · Apr 11, 2017

Thanks a lot

K9lover, ASN, RN · Apr 12, 2017

My best suggestion would be to take it one item at a time and not overwhelm yourself with the whole picture. Patient may have 100 issues but you can only address one in that instant; start with ABCs, deal with 02, move on to next indicated step. Tele patients are a LOT sicker than they were 20 years ago and transferred from ICU asap upon extubation so it is a lot to deal with. Don't hesitate to call RRT if they are crashing.

chacha82, ADN, BSN · Apr 17, 2017

Notify your charge nurse and MD that the patient is refusing an intervention. Write a note in your nurse's note for the night. Monitor the patient, continue to offer all ordered meds and treatments, etc. FYI three beats of VTACH is not always an emergency. I would conference with your charge (when they have time) about guidelines for escalating care and your unit policies.