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New nurse and critical patients

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Hi I am a fairly new nurse. Graduated from school a year ago and was hired into the ER straight away. Been on the floor for 11 months and on my own the last 5 or 6. I work at a community hospital with a fairly sick patient population, not a trauma center.

I feel like I'm okay with the normal run of the mill stuff, but I am still terrified of critical patients and I know that I need to grow A LOT in this area. The issue where I feel most unsafe is when it comes to managing multiple drips and medications. I found myself in a situation the other night where the entire ED was slammed, acuity was high, tempers were short, and help was slim, and I was getting multiple patient's that were very sick requiring medications I'd never given before, plus others I have had limited experience with. I felt so uncomfortable and had so many questions, but was afraid of annoying the my overtaxed coworkers. I felt paralyzed by the whole situation. I found the pharmacy was no help (asking how to give glucagon for beta blocker overdose - told me to read the directions in the box, which were only for hypoglycemia so they were less than helpful). Also had to give cardene for the first time (patient was in hypertensive crisis secondary to cocaine toxicity) and the drip book was nowhere to be found so I could even figure out how to mix it. Was told to switch the cardene to nitroglycerin - can I just turn the cardene off or does it have to be titrated down first? Just some examples of my questions. Other nurses either didn't know the answer, or told me information I now question after I got home and googled it. For example the charge nurse had me start the cardene at 0.5 mg/hr and titrate up by 0.5mg, but I later read to start at 5 and go up in increments of 2.5. Or was the 0.5 appropriate because he was a renal patient? All I know is the guys blood pressure didn't budge and I had to ignore my other patient's for about an hour while i played with one medication.

I felt like I needed my hand held all freaking night - and yes I'm inexperienced but I should be doing better than this! Left work with no self-confidence worried about being a bad nurse and unsafe and thinking I need to give up ER nursing (but it was my dream and I've barely started!). When I am dealing with these high risk medications I feel like a caveman blindly swinging a club, but I don't have the knowledge or finesse to manage everything that is going on, or even recognize where I could get into trouble. I get the inkling that some other nurses just hang the meds, keep the vitals stable and don't worry about anything else - let the ICU finesse everything. Is that really our role with critical patients in the ED and the best I need to do? Or am I overthinking to the point where I'm ineffective. I feel like I don't know what I don't know, therefore I don't know what questions to even ask (a mouthful, I'm sorry).

So I guess what I've come up with a long winded way of asking what resources are out there for learning how to manage the critically ill patient with multi-system issues - specifically medication centered? And given the situation above, what other things am I missing and what other things could I include in my "action plan" to improve? How do I conquer this crippling self doubt? Any advice would be welcome. Thanks!

sevo87

Specializes in SI/CV ICU and ER. Has 5 years experience.

Everyone feels this way at some point, at least you know where you're weak. My advice would be to get a pharm book or anesthesia text and learn about vasoactive drips since it seems like that is where your problem lies. Once you take care of patients like this a couple of times and see what drips work at what doses, it isn't difficult anymore. And no, your job is not to start the drip and sit back and watch your patient deteriorate; your job is to stabilize the patient to the best of your ability.

Also, there are apps you can put on your phone to help with dosages and such. I have epocrates on mine and use it when I give an unfamiliar drug. Hope this helps, and keep your head up. Before long you'll be the one helping others out.

fencer1119, Your post mirrors my own thoughts about the ED. I am now a month into my training as a new grad in the ED and have 4 1/2 left. I actually feel pretty competent with the general stuff(or at least know I will be fine with that in 4 months), but the multiple cardiac drips and meds freak me out! Everything is so fast and furious at times and I hope you receive some great advice on this post, because I will be taking notes.

FlyingScot, RN

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc. Has 28 years experience.

"For example the charge nurse had me start the cardene at 0.5 mg/hr and titrate up by 0.5mg, but I later read to start at 5 and go up in increments of 2.5. Or was the 0.5 appropriate because he was a renal patient? All I know is the guys blood pressure didn't budge and I had to ignore my other patient's for about an hour while i played with one medication."

Why on earth was the charge nurse dictating where to start a med and how to titrate? That should have been in the orders or at least verbilized by the ED attending!!!! Yes, I get that it was a crazy night, BTDT, but ANY vasoactive drug should have clear orders from the PHYSICIAN.

Flying Scot you are absolutely right. The doc had not written the order, said "get the cardene drip started" when asked for clarification said "whatever you normally start it at" Verbal orders were to titrate to a MAP less than 100. She then walked off to see other patients. I got the actual written order 40 minutes later when she put it "what the computer had as the baseline dosing."

Edited by fencer1119

FlyingScot, RN

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc. Has 28 years experience.

Flying Scot you are absolutely right. The doc had not written the order, said "get the cardene drip started" when asked for clarification said "whatever you normally start it at" Verbal orders were to titrate to a MAP less than 100. She then walked off to see other patients. I got the actual written order 40 minutes later when she put it "what the computer had as the baseline dosing.

"

That is sooo wrong in so many ways. Believe me, if the patient went south she would have thrown you under the bus so fast your head would have spun. NEVER, EVER, EVER let a physician do that to you. NEVER start a vasoactive drip without an order! Did I say "never" why yes I did. You're new, you were in over your head and you probably didn't know any better so I'm not blaming you at all. Your charge nurse should have had you clarify the order I don't care if the MD was in with another patient. Never rely on another nurse for things the doctor should be telling you. Googling the med after the fact is not acceptable either. This absolutely needs to be taken up your chain of command. Yes you should know your meds (and you eventually will) but no nurse, experienced or not, should be put in the position of guessing what the physician wants. Personally she sounds scary. I don't think she knew what the correct dosing was if her written order is as you stated. Yikes!!! This is the kind of situation where a nurse truly is risking her license.

sevo87

Specializes in SI/CV ICU and ER. Has 5 years experience.

I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.

emtb2rn, BSN, RN, EMT-B

Specializes in Emergency. Has 21 years experience.

I've never had a physician tell me what to start a drip at or how much to titrate it by.

if you don't have parameters, then aren't you practicing medicine without a license?

sevo87

Specializes in SI/CV ICU and ER. Has 5 years experience.

Let's look at a possible example. Say the medics bring you in a patient that's coding, your ER doc being such an awesome and smart guy is able to revive her with the help of your wonderful team. During all the commotion you were able to gather that she has the following: DM, HTN, CHF, previous MI. The doc decides he wants to put a swan in this lady, so you help him set it all up and he throws it in her right IJ.

He writes you the following orders: Epi gtt 2.5mg/250cc NS PRN titrate for MAP >65

Neo gtt 20mg/250cc NS PRN titrate for MAP >65 and finally in case you screw up Nipride 50mg/250cc NS PRN for SBP>160.

Now the numbers pop up and the lady has a CO of 1.4 CI 0.8 and SVR is 2750. The orders don't say anything about titrating the drips to her hemodynamics, but are you going to just let her numbers look like crap because the orders don't specifically say "start EPI at 5cc/hr, titrate by 5cc every 10 minutes to attain a CI >2"...

Edited by sevo87
not finished

Do-over, ASN, RN

Specializes in CICU.

Get 'em to the unit would be my advice. Or call them to ask for help. As I gain more experience, and work different areas I've come to appreciate the differences and challenges of different areas. Patients super unstable should be 1:1 or 1:2 (as in two nurses), regardless of location.

We have min/max rates on all our titrated drips and they are adjusted to patient response.

Do-over, ASN, RN

Specializes in CICU.

if you don't have parameters, then aren't you practicing medicine without a license?

Anyone who thinks "a nurse is a nurse is a nurse" doesn't realize how much more some doctors expect out of critical care nurses.

...The doc decides he wants to put a swan in this lady, so you help him set it all up and he throws it in her right IJ.

If you are placing PA catheters in your ED you are in a very small minority. I have been affiliated with two major academic medical centers and neither of them did this.

He writes you the following orders: Epi gtt 2.5mg/250cc NS PRN titrate for MAP >65, Neo gtt 20mg/250cc NS PRN titrate for MAP >65 and finally in case you screw up Nipride 50mg/250cc NS PRN for SBP>160.

Now the numbers pop up and the lady has a CO of 1.4 CI 0.8 and SVR is 2750. The orders don't say anything about titrating the drips to her hemodynamics, but are you going to just let her numbers look like crap because the orders don't specifically say "start EPI at 5cc/hr, titrate by 5cc every 10 minutes to attain a CI >2"...

Then you need to take this information back to the physician and ask her, or him, what you should do as your current orders don't allow for titrating anything based on any of the information you obtained from the PA catheter.

FlyingScot, RN

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc. Has 28 years experience.

I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.

And as a nurse you should be aware of your scope of practice and abide by it or else you won't be a nurse for very long.

Listen, I'm not an idiot order follower. I used to RUN codes. I know standard dosing but I always clarify instead of guess and when I was new I made damn sure I had an order and KNEW about the drug I was giving. The OP was essentially left on her own to muddle through a situation without the experience or support she needed. This should never have happened.

Do-over, ASN, RN

Specializes in CICU.

I've never had a physician tell me what to start a drip at or how much to titrate it by. As a nurse you should know that you don't start a nitro gtt out at 200mcg or a cardene gtt at 15mg/hr.

I'd agree more with this post if you had stated "as an experienced nurse with experience running drips you should know that..."

As a new or green nurse, you would have no idea how to handle it, and multiple drips would only add to the problem.

sevo87

Specializes in SI/CV ICU and ER. Has 5 years experience.

I agree with most of what you guys have said. You are right that I should have prefaced my statement with "as an experienced nurse", I'm not implying that a new grad should or would know what to start the drip at. However, unless I read it wrong didn't they state that they have a 5-6 month orientation??? I have never heard of this, and if it is indeed the case I would've expected their preceptor to teach them this, among many other things. So I guess it's more of a failure on the part of their preceptor.

Also, I am well aware of what my scope of practice includes and does not include... thats why I went back to school. :)

Do-over, ASN, RN

Specializes in CICU.

5 or 6 months sounds like a lot of orientation, but depending on the hospital you might not get to see many patients that critical even on the unit during that time. And then, ER will likely either hustle those patients to the unit (and rightly so) or to another facility. Also consider that vented patients, or patients on multiple drips would be 2:1 on the unit (or 1:1). I would think that should be the case in ER, and even though you would still likely be too busy to do a lot of research at least you can focus on that one situation.

You should look up your hospitals P&P for drips, if the ED doesn't have a copy, try going to ICU and see if they have one. My ICU has a reference binder with info on all the gtts with starting rate, max rate, etc. I have a little card laminated that I carry with me with all the info. Also on your days off, study your drugs, learn what they are for, how they work, the half- life, etc. Our MD's give us verbal orders and expect us to know how to titrate them they usually just say "start them on ____ drip". If your patient is being started on multiple drips you need to ask your charge to change your pt ratio and work on getting them transfered to ICU ASAP. It will take time to gain experience but you also have to empower yourself to learn more about what you don't know.

traumalover, RN

Specializes in ICU/ER.

everytime I've received an order for a gtt it states start levo gtt and titrate for sbp>90 or map>60. They've also said occasionally start at a certain rate but never titrate by so much, only titrate for desired effect. Could you possibly shadow in ICU for a few shifts and spend some time titrating vasoactive gtts with an experienced ICU nurse?