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

JMBnurse · Aug 13, 2012

The first year is the hardest. You will learn so much and be scared a lot of the time, but you will be an old pro before you know it. Try to resist the urge to hold medications. This is common with new graduates and can get you into trouble. Sometimes it is necessary, but not all the time. When you hold insulin, what will happen more often is a blood sugar of 400-500 later in the day and a nurse is going to get chewed out on a shift after yours when she has to explain to the doctor that a sliding scale dose was held. I've been that nurse...many times. When it comes to pain medication, you don't want an elderly patient who may not be able to express how they feel in severe pain. As a former Oncology and Hospice nurse, few things bother me more than thinking about a patient suffering. If you feel like the pain medication ordered is too strong for the patient, talk to the doctor. Maybe you could start out with a smaller dose until you see how the patient reacts. They may have a nice, normal BP and a faster respiratory rate, but are they restless and moaning? Not good. It sounds like you are carefully monitoring your patients after giving medication and that is what is most important. Assess, assess, assess. I also, have never known of a nurse losing their license over something like this. Look at your patient and trust that more than the machines in the room. I felt just as you do in my first months in the hospital. I promise, it gets easier and your confidence will improve. :)

ldegutes · Aug 13, 2012

I agree not all nurses know how to deal with insulin. I worked an impatient diabetic unit, when they were fashionable for insurance companies, and before the hospitals realized, the unit was not profitable to the hospital. Type 1 diabetics are the hardest to manage, because one min. they're high, and the next min. bottoming out. Sometimes a nurse needs to ask question, and learn. I'd never give dilaudid, if a respiration was low. I've refused to give it to a patient, and was told by the other nurses to give it. I told them to give it, the patient was already zonked out, and had a low respiration. A little more research on my part, showed the patient had gone in respiratory arrest, and had to be given narcan. The lady was a drug seeker, and I told the nurse if she wanted to give the patient the dilaudid, she could give it, it was unsafe. I am a professional nurse, and I'm not going to be bullied into doing something, which is unsafe to do.

CDUBBYA · Aug 13, 2012

If you have to question it don't do it without first seeking your CC's guidance n this and still double check trends in the patient. It is your license no matter what so who cares if a MD, OLD DOG nurse screams at you.

Flatlander · Aug 13, 2012

Hi! I was recently terminated at the end of orientation on my first nursing job. I ran across your post while still trying to understand and overcome my firing. I was struck by your description of being pushed beyond what you consider your pace for safe practice. That is exactly what happened to me in my last week of work. It was a nightmare and a disaster, and embarrassing in the extreme. I felt the other nurses were watching me and shaking their heads in pity or disgust. (I was running like a marathoner, while they sat at the nursing station and watched me go by...) The following week I was terminated.

I'm sure my behavior and responses can be interpreted in any number of ways. Believe me, I have "shoulded" myself again and again: "I shouldn't have become defensive. I should have been more careful. I should have been able to handle the pressure." Though it doesn't excuse my own behavior, part of me still believes this preceptor's manner was inappropriate and counterproductive, and not conducive to learning how to organize and prioritize.

I will take any feedback here as constructive criticism. Perhaps it will help me get things in perspective. Thanks for letting me share my honest, though perhaps misguided perceptions.

nurseprnRN, BSN, RN · Aug 13, 2012

Reality check:

Not to be nosy, but if you sleep with another adult, when you get up in the middle of the night to pee, take a minute to count resps on the other side of the bed. I can guarantee you that it will very likely be less than 12. Or try it the next time you sit behind someone on the city bus, or in a movie theater or something. I promise you that if someone is really breathing at 18 or 20 (the traditional shorthand for "normal breathing, no respiratory distress, I was too lazy to really count") (I am NOT recommending this as good nursing practice) s/he probably is in some sort of distress. Don't believe me? Sit down right now, take out your watch, and breathe every 3 seconds for two minutes. Feel like hyperventilation to you? That's because it is.

I have no idea at all where this myth that "resps below 8 mean intubation" -- they most certainly do not. I am by no means an exemplar of physical prowess, but I can often sit quietly and breathe slowly and find that I am quite adequately ventilated at a rate of 5-6/minute. Imagine: I am in a noisy hospital unit, I am in bad pain, and have been for hours, and somebody gives me a nice slug of Dilaudid. What do I do? Darn right, I nod off and sleep in gratitude and exhaustion. If my fingertip sat is ok and my color is ok, then I can promise you I'll be fine....and I will be really, really mad if you wake me every hour to check me (remember: a full sleep cycle with restorative REM is a minimum of 90 minutes). Intubation is for people who are struggling so hard to breathe they are about ready to run out of gas and stop altogether, or people who are so sluggish for whatever reason that they are not moving enough air to maintain decent blood gases. Assessment of these folks includes a lot more than mere resp rate.

I don't know if I can be the final straw that tips the scales over in saying this, but you did nothing wrong, and no one was injured because of your inexperience. This is precisely why your nurse manager is telling you you're still learning, and is smiling as she says it. Listen to her. And as someone said above, that's why God gave us Narcan and D50. No harm, no foul.

Welcome to the profession! We need you!

vickycasrn · Aug 13, 2012

I am a new nurse and also on orientation. My preceptor is great and he gives positive as well as negative feedback (constructive criticism lol). I often feel like I'm running around like a chicken without my head and asking basic questions just to double-check myself. I too lack confidence. I know with experience this will change (I can't wait to feel experienced lol). Hang in there - we will get through it!! You seem to have good critical thinking skills - you just aren't confident in them. I can relate! We both need to trust our instincts more. Sounds like you will be an awesome nurse!!

honeykrown, MSN, NP · Aug 13, 2012

Maybe my story might make you feel better (5years in nursing).

Just recently had a pt that admitted for abd pain, dilaudid ordered q2 and give with ativan. Pt was doing fine and only needed q4. Pt walky, talky, no distress, pt. joking. Gave a dose as ordered, one hr after pt sleeping snoring (responsive), an hr later pt was blue, called code, pt was fine after. Even came in aweek later and still remembered me (we didnt talk abt the issue but he didnt kill me like i kept dreaming). He spoke with me and seemed to have forgotten I landed him in ICU

What I'm saying is this you dont know how anybody is going to respond to anything. Even giving them the right dose and all the monitoring. As long as the results are not due to negligence you should be alright and learn from it. might take you back a step but u have to move two steps forward

patekgtech · Aug 13, 2012

You're right on the money. If you don't believe that it is safe to give the med, then let the preceptor stick her license out there. If you were right and the pt goes south then it's her rear in trouble. It's always easier to talk through a procedure than to get your hands dirty and "DO IT"! As a Preceptor, let her earn her pay by leading by example.

billyboblewis · Aug 13, 2012

I wonder what has happened to clinicals since I went to nursing school. I luckily went to a diploma school in a hospital and by the time I was in orientation with the same nurses that were there when I was in clincial I was pretty self assured. It is unfortunate for anyone to orient on 12 hour shifts and I am sorry these were ever allowed to be instituted. Nurses did not take advantage of additonal time off because of working 12 hours but generally use the extra days off for overtime. As far as diabetics, many may be brittle and are followed around the clock You are only responsible for them when you are on duty. If they become hypoglycemic on the next shift that nurse is responsible for taking care of the problem. You should have more self confidence and continue to ask your preceptor when you have a question or problem and charge nurse when you get done orientation. You will never go wrong refusing to carry out something you feel is dangerous to the patient and I saw one of my friends losing his license for carrying out an order after the new nurse refused....So go out and save the world while you can.

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.

Sun0408, ASN, RN · Aug 13, 2012

I can not stress enough what Grntea said. In addition, the insulin you gave did NOT cause the pt to drop that night.. If it was the insulin you gave, it would have been seen much earlier in the day.

Hang in there :)

sauconyrunner · Aug 13, 2012

Everyone else have given great advice. SO I would just like to chime in. You can do it. You will do it. and you ARE doing it well.

I'm only confused as to why on earth you are feeding a diabetic cookies.

He may have had a hypoglycemic episode anyway, it may be the way he is.

Have no fear, we all feel this way from time to time. You will get it. If you were not doing well, your preceptor would be all up your rear, I am sure. It just feels strange to be unsure. You are doing well. Hang in there, you can, you will and you actually ARE doing well.

Kasandra · Aug 13, 2012

I have to give you kudos as well: At least you are stopping, thinking about your actions, and how they will impact the care that you give to your patients. Assessing is huge. Knowing patient baselines: really important. You are already thinking in the right direction! My pet peeve is following nurses who do not critically think the way that you do: who simply give meds (or hold without follwing up) without knowing what they are giving and why they are giving it. Patient baselines change so you have to know that it is still appropriate to give the meds in a patient's regimen. And to always follow up with the PCP if you hold/question something (like meds): You are keeping your patient safe and protecting your license.

If you disagree with your preceptor's point of view, respectfully state to her why you view things the way that you do. Do not execute nursing actions at the bedside that you do not agree with: You are a RN and only you are responsible for your actions (even though you did not agree with your preceptor, you (not her) executed that action).

Always ask questions as well. Nurses who think that they know everything are safety liabilities. Give me a humble, inquisitive nurse any day to work with.

You are doing just fine. Hang in there! And keep being the critical thinker that you are! That is a strength!