"putting the whole picture together"

[iluvnoodles]

I just finally found a job and I started my 9 week orientation on a med-surg unit. My orientation has been extended and my job is on the line. My preceptors say that time management is a problem. But isn't time management the most difficult thing that all GN's have? Im told that I'm very task-oriented but somehow I feel that I'm being penalized to a certain degree, not much, but a little. When something abnormal occurs in a patient, I have trouble getting back on track. Any suggestions? And also...My preceptor says I'm "lost" and I need to be more open minded. I wasn't sure what she meant...But after a while I think she's trying to say the very same thing that my education leader said I have a problem...And that's applying my assessments to the patients and "seeing the entire picture". I think I've always had that problem but never the right guidance. I only have 2 more weeks and if I don't improve than that's it for me. no job! So, as a new nurse, how can I overcome all this? I feel that "putting the picture together" takes time and knowledge. Any suggestions to how I can "put it all together" and remain task oriented without freaking out when patient goes from stable to unstable?

"lost"

[dudette10, MSN, RN]

I'm looking forward to responses because my crystal ball on my future as a new grad shows that I might encounter the same problem.

Good luck to you!

[madwife2002, BSN, RN]

Firstly you need to sit down with your preceptor and ask her what she means, where you can improve and what can she do to help you!!!

Then come back and tell us what she said and did because it is very vague what you have been told. You need specific information

[Tait, MSN, RN]

Being only a spectator on the internet and not really knowing your story all I can offer is this little bit of advice.

Think from your patients perspective.

Sometimes as new grads, well a lot of the time, new RN's are very focused on the process, tasks and outcomes. They see one problem at a time and work to understand and apply.

As you gain experience you start to see a bigger picture of the patient. Simple example? Labored breathing. Oxygen, saturations, medications, interactions. Now you start to think "what is causing the breathing?"

fluid overload? Are they getting IVF? How much are they getting? How fast is it running? How are lung sounds, wet, crackles, rales?

CHF? Do they have a history? Are they receiving lasix? Do they have PRN lasix or a dose due now? Lung sounds? Leg edema? Ascities?

Anaphylaxis to a new abx? What have they recently received? Are they red/itchy/swollen?

(These interventions are a bit out of order)

Anyway the point is what is the general "look" of your patient? What else can be going on? Try to discover the whole "story" of why your patient is the way they are.

For example, last night we had a patient with a low blood glucose, that despite juice and crackers would only rise for a short time.

We treated the BG, and then started thinking about reasons for the low BG. We hunted websites for information on hypoglycemia in diabetics, we asked rapid response nurses, we asked other nurses, we asked each other! We delved into his chart, and talked to him about his home regiment.

Originally we were looking for a pathophysiological reason, but as we looked closer we found PO diabetic agents on his list of am meds. We found out from him that he drinks Coke and eats chocolate at home to manage his ever dropping BG's. We found articles listing a direct link from sulfonylureas + renal failure to hypoglycemia.

Overall we went from a basic nursing assessment of low blood sugar and potentially realized the danger of sulfonylureas and renal failure. Something even our RRT wasn't completely familiar with.

Anyway, in the end my point is: Think about the patient. Think about them as your mom/dad/sister/brother. Think about how each factor contributes to the overall picture. Be Sherlock Holmes :) Break it down, find the edges of the puzzle and then fill in the middle and you will be amazed to see how fast the image appears. :)

Hope this made sense,

Tait

[suni, BSN, RN]

Also, prior to starting your assignment ask to take a few minutes to review with your preceptor the patients and do some critical thinking practice. For instance, if you have a patient with a chest tube, if it is to suction, why, is it anterior or posterior, again why the placement, can you look at the x=rays, does he have an air leak, oxygen sats, mobilization etc.

[sistasoul]

To the original post. I think that learning to see the big picture takes time and experience. Right now you are just learning to get your system down. And Yes, you will be task oriented. That is what brand new grads do. I have been a nurse on an ortho/neuro unit and I am still very task oriented and am now able to start putting all of the pieces together. These types of floors are very busy and I know I don't have the time to do research as to why someone is hypoglycemic other than the fact that he/she may be on too much medication or not eating enough. I wish I had the time to do the research because it is interesting.

Putting the pieces together takes time and you will get there. I had 3 weeks of traing as a new grad and if someone had told me what you had been told I would be very discouraged. I would definitely ask your preceptors what you can improve upon and ask them for suggestions on how to improve. I know that when I did not understand something I would make a note of it and go home and try to research it. I was once criticized for taking a couple of minutes at work to look up what signs and symptoms to look for in a particular diagnosis because I was told that took away from my time management.

So don't get down on yourself. Being a new nurse is tough and the unit you are on cannot and should not expect you to be able to put the whole picture together right away. Many people forget what it is like to be new.

[ItsTheDude]

this is yet another reason why i don't go with the standard line of "new grads need to do med/surg". med/surg is just too much for some new grads and some experienced nurses, there a tons of ways to be an effective nurse outside of med/surg. i've seen way too many new grads get demoralized about nursing based on their med/surg outing. if you have other areas of interest try them, med/surg isn't all there is to nursing.

i'd try to improve at your current med/surg job, but i'd also be looking for another job, it's always easier to find a job while you have a job.

[softstorms]

You got thru nursing school, you got thru the test. Now you are on your own! Use what you have learned! If you where a Med student..there would be a time you had to cut into a real pt! NOW IS YOUR TIME! You already have the skill and the knowledge,,,,,use it. Ask questions when you have to and ask for help if you need it, but....YEP...it is your game now! Trust in what you know to do. You can't be a student forever.