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

Meebugg21 · Aug 13, 2012

Some decent advice here above.. just be sure to assess, assess, assess. Trust your gut, ask for help. Don't do anything you don't feel comfortable with.

Hypoglycemia is a funny thing--when a patient has one episode, they are more likely to have recurrent episodes in their stay. Do some research on it. Your patient might have had one previously. Just for reference here is a reference for insulin action:

Brands and Types of Insulin: Rapid-Acting, Long-Acting, and More

You should also sit down with your preceptor and discuss your feelings and needs. They should be a resource for you. I had a preceptor in the ICU as a new grad that wanted me to do everything the way SHE wanted. There are policies to follow, but individualized ways to do things, which you need to develop. If your preceptor is not receptive, go to your manager. This is a time for learning and support. If neither do so, consider finding another atmosphere that would be better for you. You need a strong foundation from which to build upon. GOOD LUCK!!

errn12 · Aug 13, 2012

I have no idea at all where this myth that "resps below 8 mean intubation" -- they most certainly do not.

I thought "below 8-intubate" reffered to Glasgow coma scale, not resps

finchfamily4 · Aug 13, 2012

I've been type 1 for over 10 years and I totally agree with veggie530. Hypo events which I've had plenty are very easily fixed. You can't always predict bs reactions I'm frequently off as much as 30% with my estimations (carb counts and insulin/bs #'s)

As a new nurse 18 years ago I messed up too. There is so much to process. Once you learn the system of the floor (people, places & things) it will be easier to focus. Say the serenity prayer and just keep swimming!

SusanRNBSN · Aug 13, 2012

First of all, I have been there. My first job was on a Progressive Cardiac floor and the pt load was usually way too high. I was lucky to have a good preceptor. Now I have been in the field for almost 3 years and work in ICU. Second, you are human first, nurse second, and NEVER God. Leave that to the docs. Third, you did the right thing going to 2 other nurses and conferring with them. You can always ask them to do it, if they won't but tell you to, don't do it. Fourth, maybe you need to think about getting assigned a different preceptor, maybe you are just not meshing. And last of all, this is YOUR orientation, not anyone else's so make sure you get what you need out of it. You are a good nurse, the thinking will come to you with time and comfort, but if something doesn't feel right you can ALWAYS consult another nurse or just call the doc. It is their job to make the tough decisions and if they tell you to do it, document, document, document.

YOU WILL BE JUST FINE!

Susie2310 · Aug 13, 2012

Dilaudid can cause hypotension and respiratory depression. If I was the patient's nurse I too would have been concerned about the patient's low blood pressure prior to giving Dilaudid, irrespective of the patient having a low baseline BP. If I was considering giving Dilaudid I would have first checked baseline vital signs, and then assessed the patient's BP, pulse and respiratory rate, noting depth and effort of respirations and skin colour, along with my pain assessment. I would have checked when Dilaudid was last given, how much, and the patient's response. I would have checked what other pain meds, if any, had been given previously, and the patient's response. If the patient was hypotensive and/or had a slow pulse and/or abnormal respiratory status and the only pain med ordered was Dilaudid, I would inform the doctor of my assessment findings, explain my concerns, and ask for orders: Perhaps the doctor will decrease the dose of Dilaudid or substitute a different pain medication etc. Of course, I would follow any current orders regarding abnormal vital signs and administration of Dilaudid i.e. giving Narcan.

I think that in these situations with a preceptor, where one feels one is being pressured to go against one's best judgement, one's best defense is knowledge and a good patient assessment. I think that if one states one's assessment findings together with one's concerns about the effects of the action of the medication (look up the med if necessary: Indications for getting; expected effects; adverse effects; contraindications; assessment prior to/after giving) and then says to one's preceptor "I feel that the patient's safety will be jeopardized if I give this medication; I'm sorry but I don't feel comfortable giving the medication," then there is a good chance your "no" will be respected. But even if it isn't, I strongly believe one has to stand firm. You did not say whether other pain medications were ordered: if they were you could have discussed giving an alternative with your preceptor. Your preceptor then has to determine the next course of action. A nurse has the right to refuse to give a medication if he/she believes it is contraindicated, and if one believes it is contraindicated it is not only one's right but one's duty not to give it, and to immediately inform the doctor of the situation. As a licensed nurse, you are responsible for your actions and their consequences.

**LaurelRN, MSN · Aug 14, 2012

Nugget...As with everyone else (for the most part)...Inexperience does not mean you screwed up...The Dilaudid...I don't know that I wouldn't have given it...Yes it can cause respiratory depression...however..."below 8, intubate" is not necessarily true..many factors go into whether we intubate someone or not...NARCAN is a wonderful thing (well to reverse narcotics) intubation is for people who cannot maintain adequate oxygenation/co2 exchange and maintain a neutral acid/base balance. translation..if they are breathing 6 times a minute and are pink, good sats, and arousable to verbal stimuli...my book- that's ok.---that said...I may hold it if they are already lethargic- depends on their pain level.

As for the hypoglycemia...nope..not on you (well..except the cookies...I mean...real sugar, high carb ones)...as said before...regular insulin is short acting...a late night, early morning hypoglycemia...nothing to do with you unless you gave Lantus or some other long acting insulin.

My one problem with your post is that your "preceptor" is barking orders to you. Though she is there to guide you..barking orders is not OK. Hang in there. You've done the hard part...you're a nurse!

Sugarcoma, RN · Aug 14, 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.[/quote']
I have never seen anyone intubated for respirations of less than 8 due to narcotic administration. Assess the patient, give them O2, and administer some Narcan. Maybe check an ABG, but intubation??? Are you maybe thinking of the GCS where less than 8 = intubate for airway protection?
And I agree with Ruby. This is not a loss of license scenario. Neither is the insulin scenario. We really do a huge disservice to our newer nurses when we perpetuate this image of the BON slyly lurking in the corners waiting to pounce at the first chance to snatch your license forever! I was told I could lose my license for flushing IV's after pain meds, for giving prn pain pills within a 2 hour window of giving IV pain meds etc. This is just not true. Do yourself a huge favor and look up your local boards disciplinary procedures and this will help to set your mind at ease.

JMBnurse · Aug 14, 2012

And I agree with Ruby. This is not a loss of license scenario. Neither is the insulin scenario. We really do a huge disservice to our newer nurses when we perpetuate this image of the BON slyly lurking in the corners waiting to pounce at the first chance to snatch your license forever! I was told I could lose my license for flushing IV's after pain meds, for giving prn pain pills within a 2 hour window of giving IV pain meds etc. This is just not true. Do yourself a huge favor and look up your local boards disciplinary procedures and this will help to set your mind at ease.

I agree with you 100%. In my state, a list of nurses who have had their licenses suspended or revoked is routinely published and it details the reason/s why the decision was made by the board. The vast majority of them are not for errors made in administering medications to patients, but for administering medications to themselves.

CherylRNBSN · Aug 14, 2012

Stop beating yourself up. (Tho I agree w others this is a very good sign!) Was the pt harmed? NO. Are you learning SO MUCH about how to handle yourself? YES.

And just to make you feel better: I am on orientation with 12 yrs of experience, but I have been away from bedside for 12 yrs., also. So I am a crazy mix of seasoned/back to bedside after long time away.

Last week, while on orientation, I gave a prn med for nausea (Zofran) three hrs. too early!! I was MORTIFIED! B/c I've been a nurse for a long time! But I was used to q 3-4 hr prn orders. Zofran wasn't around last time I practiced, and I knew the pt hadn't been medicated for nausea on my shift. I just failed to check previous shifts dosing, and made an assumption it was time to medicate.

Yes, I was mortified, but I gave myself a break. Unlike you, I had yrs. of competent practice to reassure myself with. So I reassured myself. The pt wasn't harmed (tho I was!), and I learned something.

We ALL make mistakes. Hang in there. Your judgement will ONLY get better. This is all part of it. THIS is what MAKES you a seasoned nurse. I had a dream last night about how to conduct myself my next shift. And I have to say, I gave myself some very good advice...

Something along the lines of "Get your assessments done ASAP, then focus on giving meds safely and on time".

Trust your training, listen to your gut, and DO NOT be afraid to question your preceptor. He/she should (and in all likelihood WILL) direct you.

You are going to be fine! Orientation is tough...and after that, give yourself a full 6 mos. to really be comfortable.

(((((HUGS)))))

Sugarcoma, RN · Aug 14, 2012

Dear nugget,

Here is an inescapable truth: The first year of nursing....sucks!!! You really do not know anything even if you graduated with the highest GPA ever from the hardest nursing program in the world. The best of schools teach their fledgling nurses exactly enough knowledge to prevent them from blatantly killing people and that is it! You know don't give someone with a PCN allergy PCN. lol.

A second inescapable truth: Every patient is different!!!! Low BP= don't give that dilaudid right? Well what about the patient whose baseline BP is 90/60 and needs their gallbladder out? Do you think you shouldn't give them any pain meds because it may drop their bp? So you don't give it and the pt. complains to the doc they are in pain and the doc gets mad at you right? Or you do give it and their bp crashes and the doc gets mad at you because how you could be so foolish......right?

This is what is commonly known as a danged if you do danged if you don't situation. Get used to it because they are surprisingly common. Monday morning quarterbacking is alive and flourishing in medicine and this brings us to the third inescapable truth: There will ALWAYS be someone who thinks you did it wrong. ALWAYS.

I spent the first year of nursing convinced that ANY complication my patient's had were a direct result of my own incompetence. Even if that complication arose 4 days after I had them. What did I do? What did I miss? etc. etc. I was also surrounded by coworkers who were more than willing to agree with me that yes it was my fault (it certainly couldn't be theirs right?).

Here is the fourth inescapable truth: Patients have complications! ALWAYS. Even if they get 100% perfect cutting edge medical care provided by rock star docs and nurses. They become hypoglycemic, septic, get PE's, UTI's, pressure ulcers, etc. and sometimes they even die. We cannot fix everything! You cannot fix everything!

When you are off orientation you will be able to develop your own routine. Even the best preceptor does things differently then you will when you are in charge of your own time. With experience you will develop your own nursing judgement. This judgement will guide your actions and give you the confidence to defend them when someone wants to point out that you did it wrong. This judgement only comes with practice. Unfortunately we get to practice on people. The fact that you are so bothered by what happened is good. It means you care. Care about your patients and about being competent. It is ok to admit you are unsure. It is ok to confer with coworkers and ask them what they might do in the same situation. I have even called doctors and told them look I have never seen this before and I am unsure. Sometimes they are jerks about it but more often than not they appreciate the fact that I didn't just proceed.

Identify coworkers on your unit whose practice you admire. Go to them when faced with a situation you are unsure of. Study up on medications/procedures/conditions that are common on your unit on your off days. Remember that even the best nurse was new at one time. The transition from student to practicing nurse is a rough one! Be kind to yourself and remember you need time to grow into your role.

Anna Flaxis, BSN, RN · Aug 14, 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.[/quote']
Maybe someone else already covered this, but "Less than 8, intubate" refers to the GCS, not respiratory rate.

Anna Flaxis, BSN, RN · Aug 14, 2012

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.

Low BP at baseline, moaning in pain, PRN ordered, I would have given it, too. And as others have mentioned, an RR of 10 in and of itself does not freak me out. You also need to look at the depth and quality of the respirations, as well as whether the patient is protecting their airway adequately. So, you snowed your first patient! We've all done it, and you'll probably do it again at some point in your career. I don't mean to sound cavalier; things certainly could have gone very wrong for this patient, and I'm glad you're cognizant of that, but in the grand scheme of things, I really don't think you screwed up that badly. Just learn from it and move on. Always make sure there is a BVM in the room when you do your assessment, and know where the Narcan is and how to use it.

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.

As others have mentioned, the nocturnal hypoglycemic episode most likely had absolutely nothing to do with the short acting insulin you gave him earlier in the day. Familiarize yourself with the different types of insulins and their onset, peak, and duration. As a new nurse, there is absolutely no shame in looking up medications prior to administration. Sure, it slows you down, but you get to know your meds better, and you'll make fewer mistakes. I carried my Palm Pilot in my pocket, loaded with nursing apps including Davis' Drug Guide, for my entire first year. Couldn't have survived without it!

Also, don't be afraid to read up on things at home, if you run across a situation at work that you just don't have time to do the research on. That way, the next time you run across that situation, you'll already know a thing or two about it. A lot of people believe in leaving work at work, and there are some merits to that, but I am really big on learning outside of the workplace, when you're not under the time crunch and pressure of getting the job done.