New RN, 3 weeks into orientation, total screw up.

Been there,done that, ASN, RN · Aug 13, 2012

"I am being taught to dole out medication, make sure the orders get carried out and am expected to have the knowledge of a nurse who has years of experience." Yep, that is about where nursing is these days.

You are almost off orientation and you will make these judgement calls on your own. You haven't screwed up.. you are in a learning situation.

We all know Dilaudid can decrease BP. A respiratory rate of 10 and the patient was sleeping does not necessarily mean there is a problem ! What was the pulse ox , were the respirations deep and regular and what was the decrease in blood pressure from baseline?

Maybe the patient was finally able to rest. Pain RX administration is indeed, learned over time.

Insulin administration is another finely honed skill. Each and every patient and situation is different. Many variables involved with diabetic patients. Did they eat today, did they not eat today, are they getting an infection that would change their insulin requirements...are they going to throw up their dinner?

You can and will drive your self crazy trying to cover bases that do not exist yet. Administer the insulin per order ( unless you know for sure of a huge variable) . .. and move on. That is why we have D50 and Narcan ... we can fix things that are unforeseen.

Life's Exp · Aug 13, 2012

Hi, guys! I have to say, most of my posts to this site have been pretty negative. I dislike posting so many negative things, but what can I say, I'm a new nurse and incredibly unsure.
So last week was my 7th shift on a very heavy medicine unit. The day-shift ratio is 1:5 and I was up to 4 patients by my 5th shift. I am so afraid that I am going to harm a patient, because my nursing preceptor rushes me through things. She gives me a patient load, but then instead of letting me try to get into my own groove of prioritizing and organizing, she just commands me. It's odd. I really like her, she is a great nurse, but man, I do not feel like I am getting guidance from her at all. I am being taught to dole out medication, make sure the orders get carried out and am expected to have the knowledge of a nurse who has years of experience. AHHH!!
Anyway, last week I had a patient with low bp, which has been the baseline for awhile. Pt. was somewhat drowsy, but was saying "pain, pain, pain". Dilaudid was ordered PRN and I really did not want to give it, but my preceptor and the night nurse both urged me to give it. I explained my assessment findings and their response was "oh, it doesn't really affect BP, just give it. He needs it". So I gave it. The patient assignment was under my preceptor's name, not mine. Anyway, of course the pt's respirations went down to 10 and he was just knocked right out. I checked him every 10 minutes for the entire shift, I was so scared I had just killed the pt. The MD got angry with me (and I don't blame her). I approached my manager about this, because I was so upset that I went against my gut. she told me not to worry about it, and that she was happy that I conferred with the nurses before giving it, and assured me that this knowledge and judgment will come with time.
Well I had this patient a couple days later and gave insulin according to the sliding scale. He wasn't eating very well, but I managed to get cookies and a fruit cup into him prior to me giving insulin. I went home and realized "well, maybe that was another stupid move". And it was. He had a hypoglycemic episode that night. I read in the notes that he had another hypoglycemic episode, when I was not on shift.
I am an honours student. I am a smart girl. I've never screwed up so much in my life. I feel like my critical thinking skills, once pretty well developed, are completely out the window. I can't concentrate. I have asked my preceptor for feedback and she just laughs and says "it's fine, it will take time". Now, I am so freakin scared to give insulin to people that I practically cram food down their throats before I give it. I feel like I am the worst nurse on the planet and should never have gotten into this field.

Always remember the actions you do will reflect on your nursing license. Always remember with a patient when checking vital signs (resps)) Less than 8 intubation! You stated "you were told to give Dilaudid" an the patient's resp went to 10. That is too close for comfort! You are a new nurse and I want to see your career last. So next time go to your preceptor and tell her you are uncomfortable giving that and let her do it, if any adverse reaction then it's on your preceptor's license.

Ruby Vee, BSN · Aug 13, 2012

Always remember the actions you do will reflect on your nursing license. Always remember with a patient when checking vital signs (resps)) Less than 8 intubation! You stated "you were told to give Dilaudid" an the patient's resp went to 10. That is too close for comfort! You are a new nurse and I want to see your career last. So next time go to your preceptor and tell her you are uncomfortable giving that and let her do it, if any adverse reaction then it's on your preceptor's license.

First, I'd like to note that in 35 years, I've rarely seen anyone lose their license and when I did, it was for egregious acts of COMISSION and not an honest mistake or judgement call such as giving a patient Dilaudid and then having the respirations drop. Giving dilaudid and never checking on them again until they're found cold and blue, maybe. But what the OP did is in no way license-endangering.

Second, a respiratory rate of 10 with adequate oxygen saturations and good blood pressure is a might slow, but why are we concerned about slow respiration anyway? Inadequate ventilation. Look at their color and yes, keep checking.

Third, it sounds as if the OP DID discuss the situation with her preceptor before giving the drug.

Hang in there, OP. The first year is very difficult. There is a lot to learn.

And before I forget it, sliding scale insulin is usually short acting and won't cause a late night hypoglycemic reaction. I'd be more concerned about the dose of longer acting insulin the patient got that day.

Altra, BSN, RN · Aug 13, 2012

Another thought:

Years and years from now when you are an experienced nurse ... your patients will still from time to time have adverse effects of meds, and physicians and others will still sometimes get peeved at you.

And I agree -- a respiratory rate of 10 while sleeping is not necessarily a problem unless accompanied by other concerning s/s.

veggie530 · Aug 13, 2012

Insulin admin is hard. Trust me, I'm a type 1 diabetic of 15 years and none of you nurses (no offense) will ever know as much as I do about it. I've seen plenty of nurses, some with decades experience make mistakes and bad decisions with insulin. You'll get better at it, just always try to stick to the safe side of things and follow orders to the letter.

Also note that having a hypoglycemic case is not the end of the world so long as you can give them a juice. It happens.

kdrose01 · Aug 13, 2012

Hang in there, Nugget! You will be fine. I'm a new nurse too, but I'm still searching for my first job. Be glad you found a job and remember that you still have much to learn. All these mistakes will make you a better nurse because you'll remember your mistakes. Every job takes time to learn, so be patient with yourself. Good luck!

netglow, ASN, RN · Aug 13, 2012

Totally what Ruby said.

Totally what Veggie said.

sbostonRN · Aug 13, 2012

You don't sound like you screwed up at all! Both of those situations had a fine line of judgement involved and any nurse could have done the same thing. Been there, done that said it best...this is why we have D50 and Narcan! You did a great thing by monitoring the patient and conferring with the other nurses.

Keep it up and don't be so hard on yourself. :)

ldegutes · Aug 13, 2012

I think that you are a new nurse, and lack comfidence in your abilities as a nurse. It's a shame that your coworkers, and not giving you very good advice at times. One, Dilaudid can affect the respiration, & decrease it, just like other narcotics. Sliding scale insulin is given for excess glucose, and usually acts within 15 mins. I've been a nurse for over 40 years, and you are lacking the support of your coworkers, but maybe your coworkers don't realize that you are so unsure of yourself. You need to ask for help, not try to hide the fact, because you are an "A" student in school. You only get a foundation to start with in school, and now you'll start to build on your foundation. You sound like a lot of young nurses, who think they come out of school, and should know it all. You don't and won't ever know it all. A short story, a young nurse that I knew worked with me on an ortho-neuro floor. We had been in RN school together. One day, after a hectic day on the floor, the young nurse asked me, if I learned something in nursing school that she hadn't learned. I responded I don't think so, why?. The young nurse said, I seemed to know what was going on more than she did, and thought she'd missed something, because I had handled so many emergencies, a death, and was charge nurse. My answer was, no, I didn't learn anything more than you did. I was the LPN charge nurse here for many years, and it's called experience. I have experience as a nurse and charge nurse in the hospital. The young nurse said, Whewww, I'm glad to hear that, I thought I missed something. This is a true story, the reason I showed more confidence in my abilities was because of experience. I was like every other nurse, I lacked experience, and was scared of hurting someone. Ask for help, and if you don't get it, than go to your nurse manager for help. Sometimes nurses forget what it was like to be a new nurse.

Hi, guys! I have to say, most of my posts to this site have been pretty negative. I dislike posting so many negative things, but what can I say, I'm a new nurse and incredibly unsure.
So last week was my 7th shift on a very heavy medicine unit. The day-shift ratio is 1:5 and I was up to 4 patients by my 5th shift. I am so afraid that I am going to harm a patient, because my nursing preceptor rushes me through things. She gives me a patient load, but then instead of letting me try to get into my own groove of prioritizing and organizing, she just commands me. It's odd. I really like her, she is a great nurse, but man, I do not feel like I am getting guidance from her at all. I am being taught to dole out medication, make sure the orders get carried out and am expected to have the knowledge of a nurse who has years of experience. AHHH!!
Anyway, last week I had a patient with low bp, which has been the baseline for awhile. Pt. was somewhat drowsy, but was saying "pain, pain, pain". Dilaudid was ordered PRN and I really did not want to give it, but my preceptor and the night nurse both urged me to give it. I explained my assessment findings and their response was "oh, it doesn't really affect BP, just give it. He needs it". So I gave it. The patient assignment was under my preceptor's name, not mine. Anyway, of course the pt's respirations went down to 10 and he was just knocked right out. I checked him every 10 minutes for the entire shift, I was so scared I had just killed the pt. The MD got angry with me (and I don't blame her). I approached my manager about this, because I was so upset that I went against my gut. she told me not to worry about it, and that she was happy that I conferred with the nurses before giving it, and assured me that this knowledge and judgment will come with time.
Well I had this patient a couple days later and gave insulin according to the sliding scale. He wasn't eating very well, but I managed to get cookies and a fruit cup into him prior to me giving insulin. I went home and realized "well, maybe that was another stupid move". And it was. He had a hypoglycemic episode that night. I read in the notes that he had another hypoglycemic episode, when I was not on shift.
I am an honours student. I am a smart girl. I've never screwed up so much in my life. I feel like my critical thinking skills, once pretty well developed, are completely out the window. I can't concentrate. I have asked my preceptor for feedback and she just laughs and says "it's fine, it will take time". Now, I am so freakin scared to give insulin to people that I practically cram food down their throats before I give it. I feel like I am the worst nurse on the planet and should never have gotten into this field.

wilsonbl5150 · Aug 13, 2012

I will second what has already been said/written. I'll add that a new, cautious nurse does not concern me as much as a new, gung-ho, "I can do anything" nurse.

pinkfish333 · Aug 13, 2012

Honestly it sounds to me like you are a great nurse. I made many 'mistakes' when I was first starting out and the first year of my nursing career was hell because I was so worried about everything after every shift. And u know what, six and a half years later I am just as worried but with experience you will gain so much more confidence and knowledge. I think you did the right things in the moment for the issues you mentioned. The fact that you care and are questioning every move you make will make you an amazing nurse. Keep it up.