reality check me(long)

dfk, RN, CRNA · Jul 30, 2006

if your preceptor won't respond, especially to questions and in a timely manner, then go to your unit manager.. i would, without hesitation.. sounds like these people really want to keep new staff and enjoy being "bothered".. don't be a preceptor then, ya know?

unfair to the patient at that point, regardless of outcome..

since propofol is short acting, turn back on and simply wait, with confidence, until someone can offer assistance..

i would never be worried doing for the benefit of the pt, especially if it's something i was unknowing or uncomfortable doing, for which you stated you said...

perhaps you might want to take a look at where u are and re-evaluate, especially if the "help" you are getting continues in the overwhelming flow that it sounds like~

:twocents:

p.s. sounds like u could use a few of these after a day like that :beercuphe

TennRN2004 · Jul 30, 2006

Probably part of the problem is this. If the patient is truly ready to be extubated,stable hemodynamics, ABGs look okay, you do a CPAP trial for usually 30-45 minutes. If you can keep the patient calm, encourage them it's almost time for the tube to come out, then extubating a patient is no big deal. You want to watch them really closely, make sure they don't have stridor, that they are breathing deep enough at a normal rate (mid teens preferably), satting okay, good color, watch lung sounds that pt is not drowning in fluid, etc. But, if you are a new ICU nurse, then understandably it is a huge deal. Your preceptor probably just was not thinking about this situation from your point of view. Preceptor has had tons of pts extuabated, knows what to expect, it's usually smooth if patient is stable, no big deal. But, for you yes it is a big deal, and a good healthy respect for the acuity of the ICU pt with a tad bit of fear of the unknown is vital to you succeeding in the unit. And, if something does not go according to plan, you have to know what to look for, and know what to do (ie if pt has stridor, may need racemic epi, sats crappy may need venti mask or non rebreather).

What should have happened for this to be the best experience for you and the patient is that your preceptor should have explained the game plan to you, give you an idea of what to anticipate, what happens next, what to worry about, and what is no big deal. As far as turning off the diprivan prior to extubation, I'll be perfectly honest. Our intensivist will tell us to shut it off cold turkey, half of our nurses do it, half of them don't. You are the one in the room with the patient, you know what will work best for that patient (when you gain your comfort level in the ICU, that is).

You can argue either way-for sedation up until extubation or off sedation if extubation is close. The idea being you want the patient awake enough to take spontaneous breaths (may not happen if pt is on too much sedation) so you can determine if they are ready to be extubated. But, if you turn sedation off cold turkey and pt is freaking out anxious breathing 30 times a minute, then of course extubating is going to be difficult. Sometiems you can't tell if pt is just wide awake panicking b/c they feel the choking sensation from the ETT, or if pt is agitated from not being ready to have the tube pulled and not ready to be off support from the vent. These are the pts that sometimes get "cowboy extubation"- where you pull the tube and hope pt does okay--not ever a good idea in my oppinion.

With this patient, you could have done several things for future situations like this. You could as someone else said turn the diprivan back on until pt is just about to be extubated-if I did this I would only have it low, low dose, say maybe 5 mcg/kg/min of dip, or you could try some morphine (again small dose just enough to help pt chill out a little) to help with the anxiety, and of course, you are going to have to stay pretty much at the bedside to reassure/support the patient and tell them exactly what is happening and what to expect. The other thing is to use respiratory as a reference. You could call them and discuss the situation out in the hall and let them know you're a new nurse, preceptor is tied up, you've never extuabated, could they please let you know what the protocol is for extubation. (Extremely sad to have to do this, your preceptor should be available to you at all times).

Bottom line, hang in there. You have a right to a preceptor who is always available to you. Your patients have a right to a nurse who is prepared for complications with things such as extubation. If you can't talk with the preceptor about the situation, which wouldn't surprise me if preceptor didn't have time for you while actually precepting you, then ask your boss for someone else. You don't need someone who isn't going to have your back in the unit training you. Like another post said, if the person doesn't want to precept, then they shouldn't be doing it, you're not a bother, you're learning doing what you should be doing, asking questions about something you've never seen before. Sounds like you did do a good job.

Sorry my rant is so long, but it's just plain wrong the way the newbies in the unit get treated sometimes, and it's just leaving a door wide open for something really bad to happen to a patient when you're preceptor is not doing his/her job as they should be. It does get better, the more you see, the more your comfort level will grow.

cardsRN · Jul 31, 2006

thanks for the replies guys had a better day today! different preceptor.

chaosRN, ASN, RN · Aug 1, 2006

I'm a preceptor and occasionally my orientee works on a day I do not. I always tell my orientee, if the preceptor isn't available when you them, get another nurse or the charge nurse. The nurses on my floor are almost always willing to assist the newbies. Occaisionally everyone gets busy with an emergency, and is unable to help. The orientees understand this. A bath is no reason not to help the new nurse. I'm glad you had a better day & hope they only get better & better!! :wink2: