What you wished you had known before you started your first job?

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I was just wondering if any of you would like to share with us nursing students what you didn't learn or get taught in the nursing program that would have helped you if you had known that information on your first day/week/month of your first job as an RN? Feel free to be candid. Thank you!

Specializes in ICU/CCU.

Assess every patient as if you are the first nurse to have seen them. Even if the nurse you got report from is extremely competent and experienced, patient's conditions change, and even experienced nurses can miss things and make mistakes. Check every alarm setting, every drip rate, every dressing, line/tube insertion site. Make sure that the nasal cannula/mask is actually hooked up to the oxygen source and that the lines are actually connected from the proper IV med to the patient and not disconnected and running into the bed or onto the floor and that the piggyback meds have actually been given (sometimes nurses forget to unclamp the line and give 50-100 mL of NS instead of the antibiotic).

Do not let the fact that you are following a much more experienced nurse lull you into a false sense that all will be right in your rooms. A little extra time (it will feel like a lot at first) could save you a bunch of grief later in your shift.

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Assess every patient as if you are the first nurse to have seen them. Even if the nurse you got report from is extremely competent and experienced, patient's conditions change, and even experienced nurses can miss things and make mistakes. Check every alarm setting, every drip rate, every dressing, line/tube insertion site. Make sure that the nasal cannula/mask is actually hooked up to the oxygen source and that the lines are actually connected from the proper IV med to the patient and not disconnected and running into the bed or onto the floor and that the piggyback meds have actually been given (sometimes nurses forget to unclamp the line and give 50-100 mL of NS instead of the antibiotic).

Do not let the fact that you are following a much more experienced nurse lull you into a false sense that all will be right in your rooms. A little extra time (it will feel like a lot at first) could save you a bunch of grief later in your shift.

Oh yeah, done that more than once! :eek:

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My advice is to ALWAYS work ahead. By this, I mean plan for the worst. Working ER, I don't have a clue what's coming in the door. So, as soon as I know what type of pt I'm getting from triage, I start the protocol in my head. If I'm getting a chest pain pt, then I know EKG, monitor, morphine, IV access, labs. I'll already have the EKG machine ready before I bring the pt back to the room. Abdominal pain, I know pee in cup, NPO, IV, fluids, Zofran, labs, CT. I have my supplies ready before the pt gets back to the room.

You have to stay thinking ahead and prepared for the worst. You never know when a pt may code on you. Sometimes, they wait until they get to the floor to code.

If you work the floor, I would see my stable pt first just to get them out of the way. If you are getting a new admit or have a pt that is a little more difficult, you can spend more time in that room with that pt because you have already spent time with your other pts. If a pt has 2100 and 2200 meds, try to pass them all at 2130. Group all tasks together. If you know you got to draw AM abs and do an assessment at midnight, then do them both.

Also know when to call the doctor. This will come with time. Not every abnormal lab is an emergency and can wait until the AM when the primary team makes rounds. Of course if you have a BP 210/120 and there is no PRN hydralazine already ordered, then call the doctor. If there is a critical lab value, then call the doctor.

Develop your nursing judgment. This will also come with time. If you have a pt getting Lopressor at 2100 and the BP is 130/70 but HR is 50, then you may want to hold the Lopressor. Understand how your medications work. Yes, Lopressor is long acting, but it also works on the HR as well as the BP.

Know when to ask for help and when to delegate to the next shift. Nobody wants to leave things for the next shift, but nursing is a 24 hour job. It's ok to say "I just got this new admit up at 0500 and the doctor ordered blood cultures X 2, but I just didnt get around to drawing them, so can you do them for me?"

Know not to take everything personal. When I first graduated, I thought I will come out of nursing school saving the world. However, I had a reality check when I realized not every pt wants to be saved. Some pts crave on the attention they get from being in the hospital, thus, will become that difficult pt just for the attention. Alot of pts are noncompliant. You can tell a drug addict that next hit of crack will give them a massive MI, offer social work for community rehab sources, offer Financial Services so they can get their BP medications, provide a bus pass so they can get home, and you know what? That SAME pt is back the next week with an active MI related to crack use. I had to realize it's not personal and just let it go. I've done my job by keeping that pt alive on my shift and that's all I can do. You can lead a horse to water but you can't make them drink it.

And another thing, not all pts or even you co-workers are gonna be "nice" or caring for that matter. Get use to it.

Alot of this stuff will come with time.

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My advice is to ALWAYS work ahead. By this, I mean plan for the worst. Working ER, I don't have a clue what's coming in the door. So, as soon as I know what type of pt I'm getting from triage, I start the protocol in my head. If I'm getting a chest pain pt, then I know EKG, monitor, morphine, IV access, labs. I'll already have the EKG machine ready before I bring the pt back to the room. Abdominal pain, I know pee in cup, NPO, IV, fluids, Zofran, labs, CT. I have my supplies ready before the pt gets back to the room.

You have to stay thinking ahead and prepared for the worst. You never know when a pt may code on you. Sometimes, they wait until they get to the floor to code.

If you work the floor, I would see my stable pt first just to get them out of the way. If you are getting a new admit or have a pt that is a little more difficult, you can spend more time in that room with that pt because you have already spent time with your other pts. If a pt has 2100 and 2200 meds, try to pass them all at 2130. Group all tasks together. If you know you got to draw AM abs and do an assessment at midnight, then do them both.

Also know when to call the doctor. This will come with time. Not every abnormal lab is an emergency and can wait until the AM when the primary team makes rounds. Of course if you have a BP 210/120 and there is no PRN hydralazine already ordered, then call the doctor. If there is a critical lab value, then call the doctor.

Develop your nursing judgment. This will also come with time. If you have a pt getting Lopressor at 2100 and the BP is 130/70 but HR is 50, then you may want to hold the Lopressor. Understand how your medications work. Yes, Lopressor is long acting, but it also works on the HR as well as the BP.

Know when to ask for help and when to delegate to the next shift. Nobody wants to leave things for the next shift, but nursing is a 24 hour job. It's ok to say "I just got this new admit up at 0500 and the doctor ordered blood cultures X 2, but I just didnt get around to drawing them, so can you do them for me?"

Know not to take everything personal. When I first graduated, I thought I will come out of nursing school saving the world. However, I had a reality check when I realized not every pt wants to be saved. Some pts crave on the attention they get from being in the hospital, thus, will become that difficult pt just for the attention. Alot of pts are noncompliant. You can tell a drug addict that next hit of crack will give them a massive MI, offer social work for community rehab sources, offer Financial Services so they can get their BP medications, provide a bus pass so they can get home, and you know what? That SAME pt is back the next week with an active MI related to crack use. I had to realize it's not personal and just let it go. I've done my job by keeping that pt alive on my shift and that's all I can do. You can lead a horse to water but you can't make them drink it.

And another thing, not all pts or even you co-workers are gonna be "nice" or caring for that matter. Get use to it.

Alot of this stuff will come with time.

Although I agree with this post, as a new nurse, you need to be careful that you aren't seeing stable patients first to the detriment of other less stable patients. You have to know when it's ok to prioritize this way and when it's not.

In nursing school, you will be taught to see your unstable patients first. Obviously this is one of those "real world" situations where this rule needs to be bent in order to manage your time. Keep this in mind while doing your clinicals and it should help you to prioritize and manage when you land your first job.

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omg - your post was informative and frightening! Thanks, I think :-)

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Although I agree with this post, as a new nurse, you need to be careful that you aren't seeing stable patients first to the detriment of other less stable patients. You have to know when it's ok to prioritize this way and when it's not.

In nursing school, you will be taught to see your unstable patients first. Obviously this is one of those "real world" situations where this rule needs to be bent in order to manage your time. Keep this in mind while doing your clinicals and it should help you to prioritize and manage when you land your first job.

I guess I should say on a case by case basis. Of course, if you got a pt that is going brady or vtaching, or desatting, you will see that pt FIRST, or any crashing pt for that matter. But if you have mostly all stable pts, then I will see the most stable of them all first, because if an admit is coming or if I got a pt that got alot going on (drips, contineous pulse ox monitoring, etc), but is yet stable, then I know I'm gonna spend the most of my time in those rooms.

When I was in ICU, and when I had a tele status pt and an ICU pt, I would go see my ICU pt FIRST, although they were "clinically stable". I would spend so much time in the ICU pt's room, my tele pt would be some what neglected. When I did finally make it around to the tele pt, it would be 2 hours after my shift had started. I figure it would have taken 15 minutes top to assess my tele pt and then move on to the ICU pt, knowing I would be in there longer.

I learned this from a very well seasoned ICU nurse.

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I guess I should say on a case by case basis. Of course, if you got a pt that is going brady or vtaching, or desatting, you will see that pt FIRST, or any crashing pt for that matter. But if you have mostly all stable pts, then I will see the most stable of them all first, because if an admit is coming or if I got a pt that got alot going on (drips, contineous pulse ox monitoring, etc), but is yet stable, then I know I'm gonna spend the most of my time in those rooms.

When I was in ICU, and when I had a tele status pt and an ICU pt, I would go see my ICU pt FIRST, although they were "clinically stable". I would spend so much time in the ICU pt's room, my tele pt would be some what neglected. When I did finally make it around to the tele pt, it would be 2 hours after my shift had started. I figure it would have taken 15 minutes top to assess my tele pt and then move on to the ICU pt, knowing I would be in there longer.

I learned this from a very well seasoned ICU nurse.

Of course, and I know that seasoned nurses, like yourself, know this. I just wanted it to be clear to a new nurse-to-be who may (or may not) be confused by the difference between what was advised here and what she will learn in school. ;)

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Specializes in Med/Surg, LTAC, Critical Care.

When you call a doc, have EVERYTHING available to answer questions. You can never really anticipate every question, Docs are clever critters, they will always think of a question that you are not prepared for.

Work as a team, but trust no-one but yourself. This may seem kinda cynical, but if you want to be sure something important is done, do it yourself, it's your license.

No matter how careful you are, you will eventually have the contents of an ileostomy spilled into your shoe...

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Specializes in CCU.

Just getting started as a new grad and this is a very insigtful thread.

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Of course, and I know that seasoned nurses, like yourself, know this. I just wanted it to be clear to a new nurse-to-be who may (or may not) be confused by the difference between what was advised here and what she will learn in school. ;)

Sorry for the confusion! You are right, I have to remember what they are teaching in nursing school. Sometimes I get so into reality and the real world of nursing, I tend to forget that! :lol2:

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Specializes in ICU,ER,med-Surg,Geri,Correctional.

BE HUMBLE!!! Even the gray haired slow moving nurse, who you may look a wonder why, will still have a lot to offer you, but in the same token realize your worth to the team as an equal....

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Specializes in critical care, PACU.

whenever you have idle time, do something else early. you'll be glad you had everything else done ahead of time when one of your patient crumps on you towards the end of the shift or decides to become agitated and scream at the top of their lungs while trying to jump from the bed and eat her restraints.

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