New nurse and critical patients

[fencer1119]

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!

[PMFB-RN, RN]

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

I am not sure how to respond to this because I can't determine if it is a serious question or sarcasm or supposed to be funny?

[FlyingScot, RN]

I have never worked anywhere where a doctor would tell nurses where to start and how/when to titrate drips.

Our orders are drug and what the goal is. For example "Norepinephrin gtt to keep SBP >90". I very much doubt most of our docs have any idea what the starting rate of a drip is or how to titrate it. Starting doses, max doses, and how to titrate are all in unit protocols and subject to nurses discretion.

Not every hospital works from unit protocols. And seriously, you have physicians ordering a drug that they don't know correct dosages?!

[PMFB-RN, RN]

Not every hospital works from unit protocols. And seriously, you have physicians ordering a drug that they don't know correct dosages?!

Yes I know there are many old fashioned hospitals out there. I guess I have been lucky enough to mostly work in more forward thinking hospitals who are concerned with EBP.

As for the docs, I assume so given all the times they ask us for dosages. I am not responsible for, nor do I care about what physicians do or don't know.

I am responsible for what our nurse residents know and basics of starting and titrating the dips common in their unit, and the "why" behind them.

[emtb2rn, BSN, RN, EMT-B]

I am not sure how to respond to this because I can't determine if it is a serious question or sarcasm or supposed to be funny?

I would consider an order to "hang levo" to be without parameters while I would consider an order to "hang levo to sbp >90" to be an order with parameters.

[FlyingScot, RN]

Yes I know there are many old fashioned hospitals out there. I guess I have been lucky enough to mostly work in more forward thinking hospitals who are concerned with EBP.

As for the docs, I assume so given all the times they ask us for dosages. I am not responsible for, nor do I care about what physicians do or don't know.

I am responsible for what our nurse residents know and basics of starting and titrating the dips common in their unit, and the "why" behind them.

Hey now! Not every hospital that doesn't use protocols is old-fashioned, not forward thinking or don't use EBP. Maybe they don't have the money for departments dedicated to evidence-based practice. Maybe they don't see critical patiens all the time. Maybe it's a critical access hospital that staffs only two nurses. And I'd like to see the research that says it's okay to not have specific orders for vaso-active drugs.

[FlyingScot, RN]

And just to be clear, protocols ARE orders so I'm not asking for the research on protocol-based nursing care.

[PMFB-RN, RN]

Hey now! Not every hospital that doesn't use protocols is old-fashioned, not forward thinking or don't use EBP. Maybe they don't have the money for departments dedicated to evidence-based practice. Maybe they don't see critical patiens all the time. Maybe it's a critical access hospital that staffs only two nurses. And I'd like to see the research that says it's okay to not have specific orders for vaso-active drugs.

I have worked at a number of small rural critical access hospital ERs. My experience is that the smaller hospitals need / should have more protocols than the big teaching hospitals who have residents standing around all the time.

Generally the evidence I have seen indicates that those decisions should be made as close to the beside as possible and that empowering nurses results in better patient outcomes.

[FlyingScot, RN]

I have worked at a number of small rural critical access hospital ERs. My experience is that the smaller hospitals need / should have more protocols than the big teaching hospitals who have residents standing around all the time.

Generally the evidence I have seen indicates that those decisions should be made as close to the beside as possible and that empowering nurses results in better patient outcomes.

Purely anecdotal and as such not evidenced-based. My question is, I will rephrase it, on what planet is it okay for a nurse to decide initial, titrating and max doses of vasopressive drugs in the absence of protocols. How is this not practicing medicine? Do you honestly believe that if there is a poor patient outcome the nurse will not be thrown under the bus by everyone from housekeeping to the BON?

[sevo87]

Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?

[PMFB-RN, RN]

Purely anecdotal and as such not evidenced-based.

Oh really? Um, OK then.

M

y question is, I will rephrase it, on what planet is it okay for a nurse to decide initial, titrating and max doses of vasopressive drugs in the absence of protocols.

Why are you asking that question? Did someone suggest that was OK and normal? Obviously I mean in another discussion because I have read this one and nobody is advocating for nurses deciding to initiate, and titrate in the absence of protocols.

How is this not practicing medicine?

I suggest you ask the person who is advocating for what you described.

Do you honestly believe that if there is a poor patient outcome the nurse will not be thrown under the bus by everyone from housekeeping to the BON?

I am well aware that nurses are the primary target for being thrown under the bus by everybody else in health care.

[PMFB-RN, RN]

Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?

Well said.

[FlyingScot, RN]

Unless the ordering physician is an intensivist working in a purely intensive care environment it has been my experience that they have NO CLUE what to 1. Start the drip at 2. Titrate by or 3. What the max should be. They will look at the same drug book a new nurse does to find this information.

If the doc tells you to start a Norepi drip what do you think he wants it for?? A systolic of 170? As has been mentioned previously every er or unit I've ever worked in has a drip book that gives you standard concentrations, typical starting parameters, max doses and so on. Certain drugs have different maxes from facility to facility. I'm reasonably sure that every hospital has protocols for this.

I don't get why, after having an order for something, some nurses want to be micromanaged by the MD. Why not just have him come in the room and push the buttons on the pump for you?

What poster said they wanted to be micromanaged? It certainly wasn't me. All I said was that in absence of protocols (which are defacto orders) no nurse should start a drip without a clear order. Especially not a new one.