Rookie RN - Serious Questions

I really appreciate you all taking the time. The infomation you all gave is very helpful to me.

I have a 12 week orientation and would not mind extending that time.....I feel better when someone is looking over my shoulder :)

I do ask questions constantly. I'm sure my preceptor is sometimes looking for the "off" button.

We just had an awful day yesterday - awful!!!! Out of 7 pts, 3 were "high acuity" One of them ended up coding and passed. This was my first code, I had never seen one before either. .And I have to say that my training did not automatically kick in. Why didn't I see it coming? What could I have done to prevent it? My preceptor said there was nothing else we could have done. That we had provided good nursing care. But I can't stop the thoughts rolling through my head, was there more I could have done? This is more of just a vent. I don't expect anybody to have any answers for me. I just need to share.

I have to admit that I probably learned more yesterday than I have learned in my previous four weeks of orientation. It was just a lot of hard lessons learned.

Again, I thank those who responded to my post.

Truly overwhelmed and humbled,

Flashy

Flashy,

Just want to tell you that from your questions and your reactions, I'm sure you're heading toward being one awesome nurse!

As far as the Code goes, you can work on improving your skills and reactions. Some Codes just go better than others. Some are reversible, some are not. I've come to a rather illogical but comforting philosophy about Codes--when it's your time, it's your time, and that's it. I've seen too many, I suppose. Too many who shouldn't have Coded and did, too many who shouldn't have been revived and were.

It's impossible to predict.

Just for now, trust your preceptor that nothing more could've been done for this patient. With your knowledge and skills increasing, and with medical knowledge and techniques improving, maybe in a few years, you'll be reminded of this patient and there can be something to save patients like him, Just not yet.

People will continue to die because we are all mortal.

I really see it as a good sign that you're reviewing your performance and trying to improve. But don't go into the beating-yourself-up territory; nothing can be gained from that except burnout.

Your preceptor also sounds like she rocks. She seems to be answering questions for you and in general, it sounds like you have a good relationship. Sounds like you're building a very solid foundation.

You had a trying day. Rest, relax, rejuvenate, and realize that you are doing a lot of good for this poor tired world.

:flowersfo

VTE, is that a typo or am I missing something :)

Thanks Angie, didn't know it was so prevalent!

I have the same question.

What is VTE?

Mine had multiple comorbities, but still!! not a good way to go!

I read up on DVTs/PEs and found some interesting (read: frightening) facts:

http://www.preventdvt.org/aboutDVT/index.asp

• According to the American Heart Association, up to 2 million Americans are affected annually by DVT
  
• Of those who develop PE, up to 200,000 will die each year
  
• More people die in the United States from PE than breast cancer and AIDS combined
  
• According to the American Heart Association, DVT occurs in about 2 million Americans every year.
  
• More people suffer from DVT annually than heart attack and stroke.
  
• Up to 600,000 people are hospitalized in the U.S. each year for DVT.
  
• Fatal PE may be the most common preventable cause of hospital death in the United States.
  
• Only one-third of hospitalized patients with risk factors for blood clots received preventive treatment, according to a U.S. multi-center study.
  
• Without preventive treatment, up to 60 percent of patients who undergo total hip replacement surgery may develop DVT.
  
• Cancer patients undergoing surgical procedures have at least twice the risk of postoperative DVT and more than three times the risk of fatal PE than non-cancer patients undergoing similar procedures.
  
• In the elderly, DVT is associated with a 21 percent one-year mortality rate, and PE is associated with a 39 percent one-year mortality rate.
  
• PE is the leading cause of maternal death associated with childbirth. A woman's risk of developing VTE is six times greater when she is pregnant.
  

What is VTE?

flashy,

as far as the code goes, you can work on improving your skills and reactions. some codes just go better than others. some are reversible, some are not. i've come to a rather illogical but comforting philosophy about codes--when it's your time, it's your time, and that's it. i've seen too many, i suppose. too many who shouldn't have coded and did, too many who shouldn't have been revived and were.

:flowersfo

i so totally agree with that. i decided that after i read a book about this couple that bicycled around the world. got harrassed in the mid-east, all kinds of adventures and risks. one place in the mideast they had been sitting behind the bus driver. a couple of guys from germany, i think, asked to swap places with them because the germans had been sitting in the back and weren't able to see much. the couple swapped places with the germans and in the next leg of the trip the bus was attacked and the germans were killed. they came back to this country and wrote a book about their experiences; before it could be published the wife was out bicycling, preparing for something like a triathalon and someone sideswiped her and killed her.

you just never know.

nursefirst

First thing to remember is that there is no such thing as a dumb question.

Gut instinct comes with time and experience. School only teaches you theories not the realities of Nursing.

Take ACLS even if it is not required (I hope that it is required for all tele and PCU nurses but it is only required by the CCU nurses as we respond to any code called.) And as odd as it may sound participate in any code in your area. You can only own a skill if you practice it.

And on the DVT topic, we had a lot of gastric bypass pts die of PEs even with greenfield filters and mobilizing them within 2 hours of surgery(unless they were vented.)

I will never forget my first code. To me as the new nurse, it was simply horrendous. It was a relatively young gentleman (early 60's) who had an emergent repair of a humongous ruptured abdominal aortic aneurysm. He was about 8 hours post-op.

The thing I learned the most about this is to trust my instincts, even as a new nurse. The patient was still intubated and was sedated. He began decompensating by dropping his pressure first which I responded to by paging the docs and giving a fluid blous they ordered. I didn't think much of it at first as did another nurse who was close by - these big belly patient's usually need lots of fluid resus.

The thing that began throwing up red flags all over the place for me was that even after the fluid bolus, his pressure remained low and labile and his heartrate stayed tachy. THEN I noticed changes in his ekg, specifically s-t elevation.

Immediately I notified my charge nurse with my findings, asked her to come see and bring the 12 lead machine with her and I paged the docs. They blew it off (was that because I was new? who knows?). They didn't even care about a 12 lead he said "go ahead if you want to." I wasn't going to let it go. I was scared!

As we were hooking up the 12 lead, my patient became very diaphoretic, cold, and pale. His 02 sats dropped and my charge nurse said start CPR! WHAT?!?!? So down and hard went the bed and up went me on a stool to start chest compressions after hitting the code button in the room. I did this as she paged the docs again. This time they responded but let me tell you, this resident was USELESS! The nurses ran the code until we got a doc from the CT service in the room. The CT guy ran the code (not even his patient!) for the vascular service idiot who just sat partially reclined in a chair and watched, oogling over labs and other irrevelant stuff as we coded HIS patient.

Anyway, after a while we stopped. The patient didn't make it. At first I thought this guy may have been bleeding because another assessment finding in the beginning before giving the fluid bolus was that his belly was becoming more and more distended. I let the docs know about that too on one of my first calls to them...they ignored it. I thought he was bleeding!

Let me tell you, I have never felt so inadequate in my LIFE! The family opted for an autopsy because the docs couldn't explain what happened. Like someone else mentioned here, I wanted to know the results of that autospy because I firmly believed that this guy went into cardiogenic shock due to bleeding at his graft site. And I was VERY angry that the docs didn't respond to my three calls before the patient actually coded.

It turned out that his death was caused by a massive MI (one of the many risks of this surgery) and bleeding was not the cause of the pump failure. My charge nurse and I made sure I documented EVERYTHING from the first call I made (total of 3 in about 40 minutes) to the last when another service came in to run the code. If this patient died due to bleeding my documentation covered my butt, but the response of the vascular team resident was sorely lacking (and btw, this resident was very atypical of this service, he plain sucked). If it was shown that the patient died due to bleeding, there was a HUGE lawsuit just waiting to happen.

I had to wait 6 weeks for the results of this autopsy. I asked the vascular attending each and every time I saw him (poor guy, I bugged him so much but he understood where I was coming from and from that day on had a certain respect for me). During those 6 weeks I never felt so bad. I was constantly reading and trying to figure out what I could have done differently.

When I look back on it now, I'm pretty darned impressed with myself and the decisions I made as a new grad!!!! But also, this patient was a classic AMI showing all the signs. Not every patient codes "by-the-book." It takes time and more time to recognize the sublties. Thinking back on this now, this guy's cvp was elevated, not decreased. If he'd been bleeding, his cvp would have been very very low. Also, the hct I sent with lytes when the whole thing began came back acceptable for the situation. Again, if he'd been bleeding, it would have been low. Over time, you begin to look at the whole picture instead of just the obvious.

For me, some codes go well, some don't. It really depends on the situation and who's running the code and all the people invloved. There are times when we have to do open chest in the patient's room when they're tamponading following cardiac surgery and there's no time to get back to the OR. Sometimes it's chaos, sometimes it an incredibly calm and awesome experience. It really depends on which doc is mouthing the orders and his/her temperment and personality and how they handle the stress.

When I look back on my first days in the ICU, I just can't believe how far I've come. From completely green to someone who others come to for guidance. This will happen to you too Flashy. It just takes time, but always trust your gut. It's usually right to some extent anyway and even though it's very hard, try not to beat yourself up. Make it an opportunity to expand your knowledge base!

vte = venous thromboembolism

i looked all over the site whose link was posted:

http://www.preventdvt.org/

i could not find vte defined. i finally stuck it into google and came up with the answer.

nursefirst

founding member, society for having search available on every website

What a great thread!!! I'm learning a lot of great things.

Instincts do count, but try to be specific: "The COPD patient's color was ruddy before but now his breathing is more labored, resps are high, he's c/o SOB, and his color looks dusky. Even though is vitals are ok, and his O2 sat is ok, he has deep sternal retractions as he's breathing. He refuses to even lie down in the bed due to the SOB. I don't have a good feeling about this fella right now. I called the RT, the patient had a nebulizer treatment, but hasn't improved much. Do you want ABG's? a CXR? Lasix??"

This is the perfect example of what to say when calling the doc. ESPECIALLY the end part....recommending what to do...ESPECIALLY on nights when you wake up a groggy doc.

The "I don't have a good feeling about this" is classic. When we say this to a doc, they listen.

I had a patient recently who had an extensive cardiac surgery history and was in our unit for a tricuspid valve repair (it's was he 4th open heart in two decades!!). In the past she had mitral valve repair twice and her aortic valve/root replaced. She was not swanned, but I'm sure her pulmonary pressures where just astronomical!

Here's what I said to the doc when she began to decompensate pulmonary wise:

1am - Following her midnight cpt, Ms. ______ respiratory status has been deteriorating. She became very restless and tachypneic with a rate in the forties and sats in the high 80's. She's struggling. I replaced her nasal cannula with 70% face mask. We got a gas while doing this and her p02 was 54. Since the beginning of the shift she's been on 5 liters nasal cannula. I don't have a good feeling about this. I ordered a stat chest xray.

Doctor to nurse: Thanks, give her 20 of lasix now and I'll be right there.

Within minutes of the increased 02, her condition improved greatly and a repeat abg showed a p02 of 79. That was not great given the amount of 02 she was receiving. They decided that in the morning they would probably intubate and bronch her because they knew she had a tear in her lung post-op and her sputum has been bloody all along. This is exactly what they did. The bronch was clear and we ordered another cxr and discovered a huge effusion that the earlier cxr didn't pick up (too early). Anyway, we placed a chest tube and left her intubated.

Poor lady was so sick. She was only 40.

I think my point is that over time you learn what you can do and what information to gather before calling the doc. In my situation, I sent labs, did a gas, upped the 02, and ordered an xray...THEN called the doc.

Hello - I have been an RN for about 2.5 weeks. I am currently in an orientation program for a tele/PCU floor.

I have some questions. I do not want to appear uneducated at work. But alot of things I just do not feel were covered in school or in text books. I have asked some questions, but get unclear responses.

How do you tell if a patient is going bad? I know I have gut feelings.....but when do I call the doctor? I don't want to call the doctor just because.....what are my key warning signs? I want to be able to provide the doctor with logical, objective observations that they may not have picked up on during their rounds. Do my instincts count?

When is a blood pressure too high?

When is a blood pressure too low? Is there a panic level?

What if there is a huge difference in the ortho B/P's? Do I call or just chart?

Is there any interventions I can do without a doctors order?

I know you call a code if someone is not breathing or no heartbeat. That much I did get out of school and BLS. But how do I know it is coming...... I had an instructor tell me she did not experience codes because of her excellent assessment skills. I was like *WOW*. She is super nurse. So too shall I strive........

Can anybody help me and my future patients?

Many thanks in advance.

O.k this was covered school, I hope. Your instructor is full of it. Patients code, and you never see it coming. What state did you go to school in?

OK, I've got a couple of things here:

• Re the VTE: Nurse First, thank you! I thought maybe it was a typo, so I sent an email to the site after looking all over the site to try to find out what a VTE was. So OK, next time I'll just Google it.
  
• Begalli, you are one awesome nurse. I wanna follow you around for a couple of weeks!
  
• Hollyster, your post was right on target.
  
• And Baby RN, I'm learning a lot from this thread too! This is one of the best in a long time!