Shouldn't I be "getting it" better by now?

[perfectbluebuildings, BSN, RN]

Okay I have been a nurse now "officially" since July, working on the floor on my own w/o preceptor since mid-late September. My question is, shouldn't I be "getting it" better by now??

Case in point: Last night a kid was admitted around 10 w/ what seemed to be a simple dehydration/gastroenteritis from report and orders, except that for some reason they had them on a continuous pulse ox. Then when the patient gets to the room, I look at him and his sister who is lying there in the bed next to him and think for a moment he is a doll and the little girl is the patient- he is completely still, quiet, with this expressionless expression on his face. That's not relevant except that, immediately it seemed that something was wrong; and he just wasn't acting right, then his CMP came back with a couple of critical values and another several just low, and his UA was very abnormal; it turned out he had something really serious going on. So the doctor comes in and is consulting a nephrologist at about 11:30/midnight and coming out with all these orders, and some were verbals and I didn't realize she meant me to take them immediately, I'm not sure why- she was like "We can do___ now," and I don't know why I didn't take that as a now order rather than a suggestion of something that I needed to do soon, but then in the transcription I got later she had written them as "nows" w/times.

Then I thought she was still working on his chart for a long while, but at a little after 1, I ask if she wants me to "go ahead and start doing" some of those orders and she thought she had already given me the chart and was surprised I hadn't started. Well, there WERE a lot of orders: albumin, some IV meds, some PO meds, a TON of labs, but. The resource nurse for the hospital, and my charge nurse, and an absolutely stellar PCA, helped me completely with them- I couldn't even figure out what to prioritize or where to start or anything. I really froze, deer-in-the-headlights. I mean, I knew the albumin was important, but I didn't know where to go from there and didn't think of doing several of the interventions at once. I was completely clueless when it came to this kid's diagnosis, and his parents were not expecting anything like this either and were kind of in shock.

So long story (kind-of) short, his albumin didn't finish until after 6:30 a.m. when she'd written the order for a stat 4-hr infusion at around midnight (though she still had the chart till after 1); it didn't get started till almost 2 and had to be interrupted for much-needed IV Phenergan. He was also having N/V issues that the Zofran didn't touch; they did order some phenergan IV which seemed to help but then again, he slept most of the time for about an hour before and then after that till the end of shift.

I did have 4 other kids, only 1 of whom was having serious issues as well but had been there several weeks so I am familiar with her needs; the other three I think were doing well although now I am worried about one little GI babe whose IV the MD let us leave out since she drank well in the evening, and hoping she actually was well hydrated; she did have dry lips in the morning, but the fontanel on top of her head was soft and not sunken and I couldn't tell for sure about the back of her head, where the actual fontanel was and what was just the back of her head's shape; I'd been checking the top fontanel mostly w/her asleep. I am thinking she probably woke up this morning and drank a lot too.

But anyway... even with all the help of those 2 experienced nurses, including my charge nurse checking my other charts and next-day MARs for me, I still didn't leave till 2 hrs late, and when I looked back at my charting it looked like I'd done absolutely nothing, to me, and no reason I should have been there that late. I hate when I am there late and other people have done all they can to help me; I kept emphasizing to the day charge nurse when she asked over and over if I needed help and said how sorry she was that I was there late, that people had been very very helpful all night. I don't know what I was doing!! I don't know what my problem was.

So, this loooong post is just to say, I have read other people's posts who are the same length-of-time nurses as myself and they all talk about how they had a tough night (tougher than mine with multiple patients with serious issues!) but handled it with all the right interventions and the patient did ok; what am I missing??? I just can't seem to put everything together and take charge of things myself, when there is anything at all abnormal.

I know this is kind of headlong, besides just LONG, and jumbled, so please ask me any questions you need for clarification. And please be honest, if you think from reading this, that I just don't have what it takes e.g. "nursing common sense" etc., that I am a nurse you'd dread to work with, etc. PLEASE be honest. For some reason, I have a feeling I will be called in for a "chat" w/ my manager soon to discuss why I am not getting it, and I don't know what to tell her if that is the case, because I love this hospital and I don't want another job if I stick with nursing. Once again sorry for the length, and thanks in advance for your help. I need to go get ready for work now but I will check back later if there is time.

[VivaLasViejas, ASN, RN]

Hmmmmmm........let's see now, you've been an RN for a grand total of 9 months, and you don't have it all down pat yet?? Bad nursie! bad!

I think you are being waaaaaay too hard on yourself, Rachel. You had a total of 5 kiddos---I'm sorry, but that's a LOT of pediatric patients, especially when you have a couple of criticals! You did the very best you could under the circumstances; there are times when anyone can become overwhelmed with too many things to do in too little time, and sometimes when that happens, our brains just sort of shut down and won't process the overload.

Even the most experienced nurses can't do everything at once, or be in more than one place at the same time. Your patient load was too heavy (IMHO), especially for a new nurse who's just getting her feet wet........I hope no one criticized you for staying over to do charting! Documentation is the only thing that can save our behinds if ever we are called upon to explain what we did when thus-and-such hit the fan, and if the powers that be don't like the overtime, they shouldn't put nurses in situations where it's necessary in order to complete the required charting.

Please, go a little easier on yourself and don't expect to have all your ducks in a row just yet. Time management and prioritization are skills that will come with time and practice; trust me, the longer you do this, the better you'll be, and the more you'll "get it".

(((((((Rachel)))))))

[thumperRN]

This is not the only time you will get the "deer in the headlights look" - there will be many times ahead that you will feel like you are not "getting it", but that is the beauty of medicine - it is everchanging. As are the treatments, diagnosis, meds, labs, etc.... Get that first year or two under your belt and you will be surprised what you know, you probably already know more than you think already. Hang in there. Sounds like you work with a great group of people and let's face it, we all need to depend on eachother in a field like this. Your area of expertise may be completely different from someone's else's and vice versa. I have no doubt that if you really think about it, you have helped someone else out in a sticky situation, and if you haven't, you will. There are times when circumstances can arise that are very overwhelming, and it's absolutely necessary to pull someone else in for guidance and help. It's not about "getting it", it's about being smart enough to know that you need a little help getting through the situation. There have been many times that I've asked a supervisor or fellow colleague for some assistance with prioritizing if I have a lot of orders that come through. Don't feel ashamed of this at all. It's all about learning, growing, and honing those patterns of critical thinking and prioritizing - even the most seasoned nurse learns something new almost every day.

[christvs, DNP, RN, NP]

Hey Rachel, I've been an RN as long as you (since July)& just the other evening I got a pt from the CCU & as soon as I saw him & was getting report on him, I did the "deer in headlights" thing cuz he had so much going on with him (PICC, Trach, needed deep suctioning, had tele, multiple antibiotics, PEG tube, TF, TPN going, you name it, that I didn't know what to do first, what to look at first, I ran over to my charge nurse & told her it had been many months since I did several of the skills/tasks I'd need to do with him, so she came over with me and helped me with a lot of it, and then about a half hour late, I finally calmed down when I realized it wasn't as bad as I thought. But when I first got him I was so overwhelmed I almost wanted the CCU nurse to stay with me for my shift. :) I know how you feel totally. I feel like I get it most of the time, but sometimes you can't help it, we all feel overwhelmed at times. Just be more patient with yourself I think, that is all. :)

-Christine

[ZASHAGALKA, RN]

It clicks better all the time. Don't sweat it.

It took 2 yrs before I was fully comfortable on medical (with plenty of relapses), and 2 more for critical care (with even MORE relapses.)

~faith,

Timothy.

[Indy, LPN, LVN]

I would suggest, as an alternate way of processing, in your mind, what happened, think about what the other nurses did. You're going to process this somehow or other, so try this: What did they do first? Were there any interventions they did together, or at the same time?

I'm sure you won't forget what that patient looked like! Your instinct told you something was wrong, the lab values backed it up. If you really have time, and are sort of rested, look it up and read about it. That'll also help you process the experience. It might help you rest some if you find out more about it.

Don't forget your pocket helper: notebook, napkin, scrap of paper, whatever it is that you scribble on during a critical episode. Make a point to, as soon as you see a patient looking bad, or start doing things faster than you can chart them (now orders), to scribble down what time you did what. Five hours later when you go to chart, it is a LOT easier!

You'll also now remember that when the doc says things like "we can go ahead and do this" they mean do it before they get done with the chart. It may be ok to interrupt the doc for a sec to peek at the order so you can get it done. They may be done writing orders, and looking to see if they missed something, or dictating, or whatnot. And the doctors are human too, they can forget to give you the thing you need to get started on the orders.

So don't beat yourself up. It turns out you learned a LOT and that'll help you in the future.

[perfectbluebuildings, BSN, RN]

I am sorry about the long time since I posted before replying- I worked all weekend and looked at your responses, but was too tired to write back.

I appreciate your encouragements and suggestions. I am not entirely convinced yet but I am heading that direction. I usually ask my charge nurse to assess a patient if it seems that anything untoward is happening that is not expected for that patient, but I think I ask too much sometimes about things that are not a big deal, and am rather annoying in that way- not near as self-sufficient as I'd like to be. I don't trust my own judgement completely yet.

I do like the ideas of thinking about how the other nurses handled it, and I have realized now that I had this pateint all three nights, what was going on a little better. One of his doctors explained a lot of it to me last night when the pt started having other issues (not near as serious but needed the MD and some new orders).

Marla, 5 patients is a normal load esp. on night shift, on our floor- and of course, we didn't realize this kid was going to be at all critical from what was reported; he didn't look right but we didn't know his labs were so off and he was so seriously ill. Of course, now that he's doing somewhat better, we realize how abnormal (for him) he was that first night; since that was the first time we saw him it was a little harder to judge since that was his baseline for US, you know?

(Even for his parents... he had some edema and must have had at least a bit that came up gradually for a while now, because when I was in the room after it has resolved quite a bit, his mom was stroking his face and got all worried when she felt a "bump", which I felt and it was his jawbone... She said she'd never felt that before! I wish this family had a better primary MD for this babe, but that is beside the point I guess. I am hoping, the hospital pediatricians will talk with them and maybe help them find a better one, or SOMETHING, after this; at least now he will be on the nephrologist's radar, and that will make a big difference.)

I guess, my learning curve is just a little bit longer than for some of the other nurses that came on at the same time as me- my mom has often stated I have "no common sense!" (she is right) which is very needed in nursing, maybe that's part of the problem.

I've wandered and got way off topic, but I guess to sum it up, I think I still have a ways to go before I'll feel really comfortable as a nurse. But, it is good to hear that's normal. I appreciate each one of your replies with suggestions and all different perspectives- they ALL give me a lot to think about!!! Please take care and thank you so much for taking the time to tell me what you thought :)