new nurse starting first job at a recovery/long term care facility

[amberm830]

I have been an lvn for 9 months. After finishing school I was hired on at a family physicians office. Mostly did vitals, patient history, immunizations, and blood draws ( took a phlebotomy course as well). I soon became bored and have now been hired on as a PRN nurse at a LTC. I had three days of orientation and was assigned my first shift which are 12 hours. I have 27 patients. I created my own little cheat sheets and the flow went great. They are on an emar system so I documented as I went down the hall. My problem came with administering insulin. My patient is on levamir and daily nova log and a sliding scale. Pt parameters were anything under 70 to hold. Pt accu check at 7 am was 90 trays come on the floor at 740am. Since it was my first day and nobody around to ask I decided to hold until his tray came and then give the insulin. The cna reported pt ate 70 percent of meal so I felt pt should be fine. At around noon physical therapy called and stated patient was non responsive. Patient had been in with pt for 40 minutes. Vitals were p:66 o2: 96 bp: 100/58 (which is norm for pt) accu check 90. I contacted assisted Don and Don and was told to bring pt back to hall. Once on hall continued to monitor. 15 minutes later pt was telling me lunch order and talking away. Sorry for the long post I just fill like a failure and this happening to the pt was my fault. I feel so over whelmed and scared. Assessments and wound care I handled just fine. Any words of encouragement. .... does it get easier? I am scared to go work tomorrow. I did call pt doctor advised and noted in chart and did get an order to hold the nova log until dinner.

[RNBearColumbus, BSN]

It doesn't sound like the pt's unresponsiveness was related to blood sugar. a FSBS of 90 is good, and it had been almost 4 hours since breakfast.

It's more likely that the pt's blood pressure is to blame. I'm willing to bet that the pt. had an episode of orthostatic hypotention related to activity in PT / OT. It's fairly common, especially if the pt already has a BP that is normally on the low side. Does the patient receive anything for BP? Lasix or other diuretics?

I don't think you did anything wrong here, but without knowing the actual parameters on the insulin coverage it's had to say for sure. Which insulin was to be held if the FSBS was 70 or lower? Most sliding scales start at 150 - 200, and Levamire (As well as Lantus) is usually not held at all, since it's a long acting insulin that tends to "smooth out" blood sugar spikes instead of acting immediately to lower a high blood sugar.

No, the more I think about it, the more I think the BP is the culprit here.

[amberm830]

The order stands is if blood sugar is less than 70 call md for directions on his novolog. The patient is on blood pressure medicine and has just moved to hospice. I just had a talked with the DON and she does not believe it was insulin related either and more to do with possible exertion of physical therapy.

Does the panic feeling ever get better? Should I have started someplace else? Most hospitals in my area have done away with LVNs. I did ask the DON if the assistant Don can stay with me on the hall today because I do have questions about all the paperwork.

[RNBearColumbus, BSN]

You did everything right based on the orders as they stand.

Yes, the feelings of panic do get better as you gain confidence in your skills and learn to trust your nursing judgement. Heck, I was 6 months in to pushing a med cart before I finally, really could say to myself, "Ya know? I think I've got this."

Welcome the the world of LTC / Rehab. I think (And hope) that you'll like it.

[amberm830]

So today was an awesome day. I was more relaxed and felt I actually might know what I am doing. Keep fingers crossed it goes good tomorrow :)

[abbnurse]

Glad to hear you had a good day yesterday! And yes, it does continue to get better as you gain more confidence. Every "challenging" day you get through will help you feel more confident in knowing what do when the next "challenge" comes along. Hang in there!