I am a new nurse. Just passed the NCLEX July 16 after graduating in May and acquiring a job which started June 8. I graduated top of my class. Not because I am all that smart but because I work very very hard. It's not helping me in the new job ... a busy 38-bed oncology med-surge unit at a local hospital. I had to get an actual nursing job to discover how imbecilic I can really be. My hope had been that if I just tried really really hard and worked really really hard, I'd do well. Not happening. I'm a nervous wreck. About 100 times every day I wonder if I should see a doctor, myself, and get a prescription for a beta blocker, because when I lay down at night I go over everything that happened during the shift, and my heart feels as if it will beat out of my chest and fly around the room. I'm 50 years old and should be way too mature to be having these emotional ... reactions.
Here is a list of my so-far mess ups (after only 7 weeks!!!)
1) I hung meropenem and there was still about 50 mLs of vanc left to infuse. What was I thinking? I don't know. Nothing. It was time to hang the meropenem and the pump had stopped on everything else so I just hung it. For this the charge nurse stomped down the hall, hauled me into the patient's room, and dressed me down in front of the patient. I was surprised the patient even let me into her room after that. I can only say that the patient actually liked me, after complaining bitterly of day shift's neglect. I checked on her often ... I have people skills. Too bad I didn't THINK and check the vanc before I hung the meropenem. Stupid.
2) (and very serious) I was late administering Reg Insulin. Really late. As in, about 2 hours late. I gave the Lantus but not the Reg insulin, and discovered it in a run-through of the MAR 2 hours later. Had to call the doctor and then WAIT on his call back, after checking the insulin level (which had risen), and reporting to him the value. Then I could administer the late dose.
3) Didn't know how to interpret under the "orders" tab and so didn't put telemetry on a patient who had come in for DKA. On shift change the nurse I was reporting off to asked me about it and I was like ... "duh ... what?" and had to put on the telemetry before going home.
This is not to mention that I am slow at EVERYTHING. And it makes it even slower because I can never find my preceptor to ask things. Protonix? It comes in a powder. Great. I didn't know what to reconstitute with and couldn't find it on the little vial. Had to find someone to show me how to do it. So another nurse notices how long it took me to administer this because it takes long to find someone, gather the necessary materials from the overwhelming supplies room (where nothing seems to be in logical order) and administer, and tells me she's glad she's not my patient. Not to mention it was only LUCK that I looked it up in the computer and discovered it needed to be administered over 2-5 minutes, or I would have pushed it at lightening speed and maybe done some damage.
I swear, too, that if I had a nickel for every time someone has said to me or asked me "didn't I tell you this before?" or "your license is at stake!" or "you must go faster!" etc., I wouldn't owe anything for my school loan. It'd be paid. My list of fantasy comebacks is growing ...
The other night I tried to administer a PRN percocet (PO) to a patient, and the minute the pill touched the back of this poor lady's throat, she spit it out and began to cough. Hard. Then gasp. Drool coming from her mouth. I had no idea what to do besides raising the bed and patting her back ... and I called for help. Immediately 4 nurses and 2 young doctors in the room. And we all stood there and watched her get over it gradually. I was told I over reacted and that my problem (among many) was that I was always looking for zebras and there are only horses. I need to get out of the HURST mindset where every symptom is one where the patient is potentially dying (and if I don't recognize it I am a scary nurse ... which of course I already AM a scarey nurse) and recognize the horses, so to speak.
I made up a new sheet for myself - since the hand-off sheet is confusing to me and doesn't help with med administration. It DOES help me, but I've been told numerous times that it's no good ... I shouldn't be using all that paper I should just be writing down times of administration, not meds, or should be remembering things, or writing down the first letter of every med, and then not taking the WOW into the pixus room. And I definitely shouldn't be standing there with my sheet asking the handoff nurse questions and writing down her answers to fill in my sheet ... it's insulting to the handoff nurse. And I should not trust anything the handoff nurse says ... I should check the WOW myself, because she could be mistaken and my license is at stake. So what good is a handoff? Apparently just to report what the patient did on the last shift. Everything else should be gotten from the machine. Only there is little time to gather the information from the machine. It does no good to come in early because they don't make patient assignments until 5 minutes before shift change. I could REALLY use them doing it before that, and would get my "stuff" together off the time clock, so that I'd have more of an idea of what was going on, before shift change. 15 minutes after report people are asking me if I've made rounds on my patients (I'm supposed to have done a head to toe on 6 patients in that time period, like everyone else does).
Anyway ... I'm not doing well. I'm seriously not doing well. They've put me on an extra week of orientation. I feel like I could use another 4 weeks of it. They said they're taking it week by week and tried to be very reassuring that so many new nurses have been through this. And I've been switched to day shift for a week, so that I can precept with this other gal, who the Nurse Manager says is more like me and "quiet" ... which, I'm not all that quiet, but seem so when I go to work. Sitting there in the Nurse Manager's office, I was trying to be very calm and professional, but was preoccupied by my uncontrollable mouth, which wanted to quiver. Geez. I wasn't about to cry but my mouth disagreed. I have not told anyone except my best friend about this. Too humiliating. Will I be a bad nurse? Is this a bad omen? Am I only fit to sit by someone's side and pat their hand? Heck it's my only skill. Oh except for charting. Apparently I'm a rock star when it comes to charting, and apparently this is an unusual skill for a new nurse. Not exactly going to help anyone get better though, being good at charting, which carries no stress because no one ever got hurt or sick from a nurse forgetting to chart gastrointestinal sounds, have they?
Specializes in Med-Surg; Infectious Diseases; Research.
Are you always this hard on yourself? You are a new nurse and oncology is tough, so give yourself some grace. And 7 weeks is not a lot of time to learn anything. I always tell new nurses, do not rush off of orientation! Once you're off, managers are a lot less forgiving. Are you in a Nurse Residency Program? Seven weeks is short for an oncology unit. Is it possible for you to switch to another unit? If you graduated at the top of your class, then you definitely have the intelligence to be a nurse. Something tells me you keep getting stuck in your own head. Are you focusing so much on not messing up that you are unable to absorb new information?
Now that you've made those mistakes, you'll never make them again. Time management is the biggest hurdle. Once you can get on auto-pilot with certain things, then other tasks won't seem as daunting. I agree with your colleagues, the nurse reporting off doesn't need to tell you all the meds she administered. You can look in the system for that. Legally, what matters is what's documented not what's said. So don't rely on handoff report. As you listen to report, focus on exceptions to normal. One way I trained myself to think head to toe was I would take my patients summary sheet, fold it in half vertically so the blank side faced me. On the left side, I would list Neuro, Diet, Procedure, Resp, Card, GI, Skin, Pain, IV, Pain, Misc. and would write any exceptions to normal provided in report. On the right side, I would list the same systems again but only what occurred on my shift. The right side is what I would report off when I left. I did this for each patient.
After report, always eyeball your patient. Talk to him/her. Introduce yourself. Pay attention to how they respond to you. Do a quick assessment, eyeball any bags hanging. Then go check your medical record. Make yourself a schedule of what meds you have to administer and when. Cluster your meds - use the 1 hour before or after window so you're not running in the patient's room every hour.
I did this every shift until I got into a rhythm. Soon my Preceptor didn't have to ask me for things. I was always a step ahead of her. Good luck :-)
P.S. Your age has nothing to do with your performance. Don't talk yourself out of being successful. One of the best nurses I know didn't come to nursing until she was 55
OP--I think that at our age, it is often a matter of "I am wayyyyy too old for this nonsense!!" of drama making when there needs to be none. To "dress you down" in front of a patient is not professional, and not in the patient's best interests to have to be a party to.
And all of these "faster/faster" comments....honest to Pete, give me a break. You need to be safe, not fast. This is not a race.
If you have a paper that works for you, keep on using it. I would use a couple different color pens to coordinate "odd" medication times, so that you remember them. Highlight your diabetics so that you remember to deal with FBS and insulins. See if your policies on antibiotic infusions can have a flush bag as a flush between medications may not be a bad thing. You can get that information from your pharmacy as well.
Please don't think you are "disrespectful" when you are asking questions and writing down during report. But I would look at the chart before doing anything. Just a quick "is there new orders" and note medication times, and anything else that requires your attention during your time.
Lastly, I would invest in a drug reference book, as well as an infusion book. Both of which could help you look up what you are giving, how to reconstitute it if it is needed, and the infusion time.
You will get all of this--but you need to know that your way of organizing yourself is not everyone's way....and that's OK.
1. It sounds like your charge nurse is riding you. They followed behind you to make sure the entire bag of vanc infused? Them bags of vanc are 250ml minimum, so the patient got the vast majority of the dose. I can't even count the amount of times I've seen 50ml IVPB abx infused with primary tubing and about 20-25ml remaining in the line before they were heplocked. I've even seen the abx hanging clamped hours after it was scheduled to infuse. Addressing this issue in front of the patient is unprofessional on behalf of this charge nurse and I would think your facility would frown upon it. I would speak with the nurse manger.
2. Very serious, what was his level? Regular SSI at my facility is ordered PRN since it can be given multiple times throughout the day. How could it be late if it is PRN? The lantus is timed though. Why was the physician called? Is 9 units at 9pm not the same as 9 units at 11pm? I don't even think another accucheck would be indicated in this situation. I would have just given the sliding scale without informing anyone other than the patient. That isn't against any rules or policies in my facility, but it could be in your.
3. I've done this myself a few times. I've always caught it within a couple of hours and the patient were in the same rhythm as their initial EKG upon arrival. Most t-techs give a courtesy call if they are unable to send someone to hook it up. With DKA you should be more concerned with your q1h accuchecks and titrating you insulin gtt if ordered. The tele is still very important for a patient this high in acuity especially if there is a significant cardiac history. At least it wasn't a patient with a trop of 20.
4. Dilute the protonix with a 10cc NS flush. Quick and easy.
5. Be careful when administering po medications to the elderly. They really can choke and die or aspirate. Don't leave them laying supine with a mouth full of crushed applesauce meds after their 10mg IM dose of zyprexa, lol. It was unfortunate that other nurses and physicians got involved since it really wasn't much of an incident.
As for your HURST worrying. Your most important tool in determining stability are the vital signs. They are typically the first indicator that a patient is going bad. Watch out for the patients without telemetry, if their rate is 120 they might be in afib, especially if their baseline was 70 when they arrived. Watch for low pressures and tachycardia, you patient could be going into septic shock. Watch for CHF patients on the ortho floor being fluid overloaded by the orthopedic surgeon. Watch out for any AMS (altered metal status) patient, if they have COPD and AMS make sure blood gases have been checked, you may or may not notice changes in their respiration. Watch for CVA and DVTs in you post ops. When a patient makes a complaints, if you are unsure ask them if this is unusual for them. If you have electronic medical records click on the select visits tab and make sure the patient hasn't came in through the ER for chest pain 100 times last year. Don't waste your time with the seekers, no amount of dilaudid and phenergan will satisfy their sweet tooth. For the young repeat DKAs, I typically make small talk about DM and ESRD.
Out of all the problems you mentioned, the only significant error I see is the telemetry mistake. It sounds like the other nurses on you floor might not be the friendliest group, some units can be cliquish. If your charge nurse tells you to notify a physician over minuscule problems, I would be sure to tell the physician you were told be call by (first and last name charge nurse). The charge nurse is not your boss, if they have a problem is that significant they can call the doctor. Always be sure to get bedside report and check any surgical, venous access, and cath sites while in report. Getting a crappy report from time to time is inevitable.
I hope everything works out for you. Sometimes changing or departments or simply changing the day you work can make all the difference in the world. Good Luck!!!
If I were you I'd run from that job like I was on fire. You're not getting the support that you need as a new grad on an acute floor. Do you have a department educator you can address your concerns with?
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
The first year of nursing is especially difficult, and you probably won't distinguish yourself as brilliant until you've been at for a few years. In fact, if you manage to get through the first year without distinguishing yourself in some NEGATIVE way, you're doing brilliantly.
As far as mistakes, everyone makes them. As a new nurse they're both more obvious (because yes, people are watching you) and more terrifying. I learned (the hard way) that patients can survive all sorts of nasty mistakes as long as you: 1) Realize that you're going to make them sooner or later and are thus open to recognizing one when you've made one, 2) Admit it when you've made a mistake and 3) Immediately set about notifying the appropriate people and mitigating the damage to the patient.
Your career will survive mistakes, too, as long as you do the first three things and then: 4) Be the first person to inform your manager about the mistake (text or email her if necessary), 5) communicate to the manager that you are horrified that you made a mistake because of the potential danger to the patient and 6) Identify how you've learned from the mistake so it won't happen again.
My career (and my patients) have survived some really dumb mistakes. Most nurses can probably tell you something similar.
As far as handoff sheets (or brains), use whatever you need to. But first check to see if there's a standardized sheet that your unit prefers. If you can organize yourself around that it will help you in the long run.
Good luck! As I said earlier, the first year of nursing is miserable, and in order to get through it, you have to GO through it.
When I was a new grad, I got paired with a preceptor that was impatient and hypercritical. He was a good teacher but didn't have any tolerance for slow learners. I graduated nursing school with all sorts of awards, but I was convinced after my orientation that I would be fired. Over two years later, still working in the same ER and my preceptor now brags on me :) I made mistakes, everyone does. We have an LPN in my ER that has been around the block a time or two that told me that when my preceptor was brand new, he tried to give Levophed IVP. And he is a Damn good nurse, which goes to show that everyone makes mistakes. Being a new nurse is a big learning curve. You'll be fine.
Well that was an intense read. Pretty much what I'm getting from this is you're a new nurse who has made some mistakes. We all make mistakes as nurses, as humans. The important thing is you learn from them and don't let them happen again. At least you're at an age( I'm half of your age) that you realize you need to fix these mistakes and get better. When I first came out of NS I thought it was no big deal, whatever. Obviously now I'm older and realize every little thing in the nursing world matters. The mistakes you have listed I bet don't happen again. However if they do that can become a problem. That nurse who belittled and tore into you in front of the pt was unprofessional. One day you'll be the vet nurse talking with a newbie. Take a breath and strive to be the best nurse you can be.
I absolutely love your response. So many times the people on this forum make snarky comments as if they have never made one mistake in their life. I felt like you gave encouragement to this new nurse which is what he/she needs right now. Thank you for being human.
I really appreciate you sharing your fears with us. I am embarking on my final semester of nursing school and I am reasonably fearful of what lies ahead as I prepare for my new career. It's nice to read about real life experiences that others have encountered.
I think you are no different than so many other new nurses out there. You've been through school, the clinical experience and now you are out there seeing how different school is from the real world (as I'm told).
Keep your head up, work harder at being a good nurse and tell those who say you are too slow that you'd rather be slow than defending your license.
Hi guys :) Well I completed my first week on day shift ... WAY different from night shift and harder. Harder as in, doing the discharges, putting in orders, going to different screens to FIND the orders, etc. And I'm going to be on yet another week of orientation, in the day shift. I'm pretty glad of it. Still haven't told anyone except my best friend and of course, you guys, but my attitude has improved and so have I. All three days I've asked my new preceptor for her evaluation, and she's had very little to say. I'm doing a good job. Time management is my best thing ... always has been. Interruptions (that stupid zip-it that's always ringing) still throw me off and I don't even want to know what my blood pressure is these days. I took a benedryl the first two days of day shift, thinking it would help my calmness, but really didn't see any results, and forgot to take it the third day so that solution is out. Kind of crazy anyway. But I'm doing better! I actually got .... (gasp) .... compliments! I purchased two pens that have different colors available, and instead of a clip pad I'm carrying around a notebook, so that I can keep organized. Much better. When I get more experience perhaps I won't need it. I have also been working on my "Buddha face," and what comes out of my mouth. It needs to be positive. And I finally managed to start an IV yesterday on a cancer patient! Dear heaven. I was too busy to turn a cartwheel down the hallway but thinking of it today I feel pretty good. Day shift? The days whiz by. No pesky down time that drags, like in night shift. I like that. If I can just learn the different screens and how to put in orders and find the new orders, I might make it. I need another week. So I'll be working Monday, Wednesday and Thursday, day shift this week. Probably going back to night shift after that but I sure wouldn't cry to be put on day shift. Nicer crew with which to work. I'm so happy to have found this board and to read everything that you guys had to say, and really grateful to you all. Thank you all so much!!!
DrKim
48 Posts
Are you always this hard on yourself? You are a new nurse and oncology is tough, so give yourself some grace. And 7 weeks is not a lot of time to learn anything. I always tell new nurses, do not rush off of orientation! Once you're off, managers are a lot less forgiving. Are you in a Nurse Residency Program? Seven weeks is short for an oncology unit. Is it possible for you to switch to another unit? If you graduated at the top of your class, then you definitely have the intelligence to be a nurse. Something tells me you keep getting stuck in your own head. Are you focusing so much on not messing up that you are unable to absorb new information?
Now that you've made those mistakes, you'll never make them again. Time management is the biggest hurdle. Once you can get on auto-pilot with certain things, then other tasks won't seem as daunting. I agree with your colleagues, the nurse reporting off doesn't need to tell you all the meds she administered. You can look in the system for that. Legally, what matters is what's documented not what's said. So don't rely on handoff report. As you listen to report, focus on exceptions to normal. One way I trained myself to think head to toe was I would take my patients summary sheet, fold it in half vertically so the blank side faced me. On the left side, I would list Neuro, Diet, Procedure, Resp, Card, GI, Skin, Pain, IV, Pain, Misc. and would write any exceptions to normal provided in report. On the right side, I would list the same systems again but only what occurred on my shift. The right side is what I would report off when I left. I did this for each patient.
After report, always eyeball your patient. Talk to him/her. Introduce yourself. Pay attention to how they respond to you. Do a quick assessment, eyeball any bags hanging. Then go check your medical record. Make yourself a schedule of what meds you have to administer and when. Cluster your meds - use the 1 hour before or after window so you're not running in the patient's room every hour.
I did this every shift until I got into a rhythm. Soon my Preceptor didn't have to ask me for things. I was always a step ahead of her. Good luck :-)
P.S. Your age has nothing to do with your performance. Don't talk yourself out of being successful. One of the best nurses I know didn't come to nursing until she was 55