New RN and panicked/struggling

NsgChica · Apr 1, 2008

Redwood, try not to panic. I understand that this is easy for me to say but I am sure that similar situations like this has happened to other nurses. If you are upset, maybe try to talk to your nurse manager. He/she may be a great resource in this situation. If you don't feel comfortable with your manager try speaking to the nurse educator. It's sad the way your preceptor handled the situation. I am sorry to hear that. Sending Hugs your way!!!

NsgChica · Apr 1, 2008

Also, it takes time to develop those critical thinking skills. Have you ever read Pat Brenner's (I think that's the name) article novice to expert? She talks about the development of critical thinking in the new nurse.

redwood · Apr 1, 2008

Redwood, try not to panic. I understand that this is easy for me to say but I am sure that similar situations like this has happened to other nurses. If you are upset, maybe try to talk to your nurse manager. He/she may be a great resource in this situation. If you don't feel comfortable with your manager try speaking to the nurse educator. It's sad the way your preceptor handled the situation. I am sorry to hear that. Sending Hugs your way!!!

Cardiheartnsg, Thank you for your advice. I will talk with my preceptor about my eval and today and ask her to help guide me so I know what I am doing wrong in my techniques. Maybe I misinterpreted her reaction today; she may have trying to remain calm b/c she saw how upset I was. I really respect my preceptor and I enjoy working with her, she is smart, personable and just an awesome nurse...I feel blessed to have the chance to orient with her. I hope I didn't sound otherwise, I think I was just analyzing it emotionally. She is there to help me; I think I just have to ask, and not be afraid of looking dumb. I just want to be the best I can be. I just pray my patient is going to be ok. Thank you again for your support, I feel a little better now.

NsgChica · Apr 1, 2008

Awwww...anytime! I am glad that the advice was helpful.

paxpax · Apr 1, 2008

I have been unsuccessful in starting IV's, obtaining ABG's and blood samples and I feel so pressured to perform, especially b/c I have a RN, BSN and previous degree and career.

I am 6 months on my own on a busy tele unit. I still can't start IVs - I blew an easy one tonight and had to get help. I couldn't do ABG's if I tried, though our respiratory people do that. I also have a RN, BSN and previous degree and career I know just how you feel. I am sure you do MANY things well. Think of some of the people you used to work with - Can you imagine them doing what you do now? Being a nurse takes a special person. It's a calling. It just takes time.

CABG patch kid, BSN, RN · Apr 1, 2008

I've seen a nurse with 2 years experience let an IV infiltrate so bad that the poor guy's arm was swollen from wrist to elbow, and the IV site looked so incredibly junky I don't think she had looked at it all shift, otherwise she probably would have d/c'd it.

Point being, even experienced nurses make mistakes. The thing is that we newbies need to LEARN from our mistakes now so we don't make them again. I made my first med error the other night and I tell you what, I will not HESITATE to call a pharmicist if I ever have a doubt in my mind about a med (which I did before I gave it anyway, in a hurry )

Just keep plugging along, you say its only been 4 weeks, you've got plenty of time to learn. You will not even begin to feel comfortable until about 6-12 months of being on your own. Never hesitate to go to your coworkers for help or with questions, and if you feel its not being addressed well enough on that level, go to your manager or education resources. Take time at home to read about things you are uncertain of (good job reading up on IV infiltrations, knowledge is power!)

Good luck to you, this first year will be hard for all of us new nurses, thank goodness we can come here for support!!!!!! :nurse:

UM Review RN, ASN, RN · Apr 1, 2008

She had vanc running at 100 mL/hour. She continued to complain and my preceptor told her the new site was fine, and it was, there was no swelling, etc. About 1/2 hour before shift change, I go to her room to find her crying and her arm swollen and hard, her fingers looked crippled!!! I couldn't believe what I was seeing! I never saw this before! I had checked on her about 1 hour before and she was fine. My preceptor was there and didn't say or do anything, just went back to what she was doing with her patient in the next bed. I panicked and cut off her ID bands because they were cutting into the skin! My preceptor told me to take the IV out, which I did.
I reported it in shift report and neither my preceptor or the other nurse seemed concerned. Tonight I looked infiltrated IVs on line and learned that tissue damage and nerve loss can occur! And people have sued over this due to loss of function in their arm!! I am panicked and have cried all night, I'm petrified to go back to work and that I'm going to get in trouble and lose my license. I can't stop worrying about my patient and her arm. I feel horrible and guilty that this happened, b/c if I had instincts, I would have known to sit with her and watch the site to make sure it would be ok until my shift was over. What did I do wrong????

Please stop beating yourself up. You are new. You can't go from being inexperienced to being experienced in one day.

I also used to beat myself up over mistakes. Try a new tactic: Make yourself learn from your mistakes. It's not going to make you cold and hardhearted to admit that you made a mistake, learn from it, and move on. In fact, in the long run it will benefit future patients. Beating yourself over the head with a mistake will only increase your chances of burning out.

You need a better coping strategy. Mine was to learn as much as I could about the problem, so I'd be better prepared to tackle it the next time. And believe me, with IVs, there will certainly be a next time.

Your coworkers were blase about the IV infiltration because infiltrations happen, as you just saw, even with a lot of vigilance. After seeing the arm, you did the correct thing to cut off the bracelet.

I would've also called Pharmacy and if you have an IV team, I would have called the IV nurse to ask what to do next and what to watch for. I would've put the arm in an elevated position on a pillow and used a warm/cold compress (warm or cold, let the IV nurse or the Pharmacy decide) to alleviate pain and swelling.

For something like Vanco, I might have even called the doc and explained the situation (hard stick, lost a couple of IVs already with infiltration) and if the patient was going to get a long-term IV therapy, I might ask the doc if he/she would consider placing a PICC line.

These are all things I've learned as I did them, in much the same way that you're learning them. You'll learn an awful lot just reading the threads on this site, also.

Our hospital also requires things like that to be reported to Risk Management. Frankly, we rarely report "plain" IV fluid infiltrations, but we would report an infiltration from any medication. There are quite a few that can cause problems if they infiltrate. Document all your interventions and patient responses carefully.

I had one patient whose arm blew up like a balloon from 3% saline and I was terrified that it was going to cause necrosis. The patient insisted she was fine, never even felt the edema, indulged me when I did all the interventions I could think of, and exactly two hours later, the arm was back to normal. I honestly thought it was a miracle at the time, but have since learned that we are usually told about the worst-case scenarios.

Finally, you have learned Rule #1 of IV's-- if the patient c/o pain at the site, even if you don't see anything wrong, even if it flushes and aspirates fine, consider starting a new IV somewhere else. Often the patient is your first clue that an IV is going bad.

Here's a good learning resource Web seminar regarding IV infiltration/extravasation:

http://www.mcdcommunications.com/streaming/dri/ins2007/baxter.html

nursemike, ASN, RN · Apr 1, 2008

Just want to say ditto to what Angie said. If the IV was good when placed and had a good blood return, watching it for a couple minutes when the vanc started and checking every hour as it ran was due diligence. Pt may have dislodged it, or it may have just blown. On my unit, we do dilantin IVs fairly often (more often than we like, but no more than we can avoid, because dilantin IVs are dangerous). At one point, I felt bad because I had been doing dilantin pushes undiluted, very slow (3-4 minutes) and a more experienced nurse questioned my pushing undiluted. My drug guide said nothing about dilution, and I'd never had a problem, but after a sentinal event, we were all inserviced and warned not to dilute dilantin.

One thing one of my mentors taught me, and a lot of my coworkers don't seem to heed, is that the suggested rate on antibiotics is a maximum. If I get a 500ml bag of vanc that says infuse over two hours (250ml/hr) I never run it at 250 through a peripheral. I run it at 200, tops. If I get a 50ml bag of Fortaz to run over 15min, I run it at 100/hr (30 min). Sites seem to last a lot better for me than for some others. But I agree with Angie, if we're going to be running a lot of antibiotics, we start squawking for a PICC order right away.

As for the rest, it's fairly normal to be pretty scared, the first few months. It's a lot to learn, and much of what we do is pretty darned important. There has been some discussion on these boards, lately, about how schools/hospitals could do a better job of preparing us, but honestly, I don't think there is any way to make it easy. Practice and mentoring are important, but sooner or later, you're working on your own, and that's pretty intimidating. Or, at least, if you are taking your responsibilities seriously, it is.

I have a theory that you have to miss 100 IV sticks to get good at it. You miss the first 30 pretty quickly. Missing the next 40 takes a while. I'm in my third year and still working on missing the last 30--misses are getting few and far between, though last weekend I had a pt nobody could stick. Her veins were so tiny that a peds stat nurse came up and tried a 24g. We ordered a PICC, but the patient went home before she got it, so she never did get her heparin drip. Bummer, but I hope she's okay on PO coumadin, or whatever therapy the docs eventually ordered.

I did buy a tool called a Venoscope. $178 for what's essentially a fancy flashlight. I hear you can get similar devices cheaper, maybe on e-bay. It shines through the subcutaneous tissues and the veins show up as dark lines. It's far from foolproof, but I find it useful. Sometimes all it tells me is where not to try. Our best sticks work mostly by feel, but it helps me if I can visualize the vein, too.

I understand all too well where you are. Been there, myself. Anxious to the point of GI symptoms. But you will get more confident, and hopefully you'll stay careful.

cpnegrad07 · Apr 2, 2008

I'm new, too (2 months on my own now) and something i try to do is reflect on what i learned during the shift--while i'm driving home. I re-run things that when wrong, why, how to do it better next time. And i go over good moves i made to re-enforce them. And i try to think about the BIG PICTURE for the pt--why are we doing certain things for them, where are we trying to take them. These are all things i don't have time to do today at work but that are going to make things easier in the future.

Usually i start the commute with the radio and end up turning it off at some point to have this conversation with myself.:heartbeat