When is it too much? (long)

[CyndieRN2007]

I'm just alittle bothered by a statement that was made about me when I was on our last rotation on Surgical floor. We were PN students, and we all had two patients. I had a 82 year old man admitted for urinary retention who cut off his foley at home. My other patient was a 19 year old gunshot wound victim. He apparently shot himself in the leg. Ok, there's the backround. Being a PN student, I wanted to absorb every little thing that there was to learn. I am very anal about details, rules, and all that. My gunshot wound vic was given morphine at about 1430 and then was asking for more pain meds at 1515. I asked to give him hydrocodone. Checked respirations. 16, ok. Pain scale 8/10. Gave him the med. The primary nurse that I was assigned to told me to keep an eye on him. Checked on him 30 (1630) min later, pain scale 7/10. Asked for more meds. Checked respirations, 14. Speech was alittle slurred. I was starting to wonder if he was getting too much. I notified my instructor of this. I told her that I thought his pupils were pin point 2 mm. She went in to check on him, and she agreed. She told me notify her if he wanted more pain meds, within the time frame of course. Now, I know about patient pain management importance. I was just concerned. After shift change, the new nurse on duty pushed morphine again, about 1930. After that, his speech was very slurred, eyes pin point, resp 12. Primary nurse seemed to be okay with it. Instructor told me to chart what I saw, just to cover my tail. Before I reported off, the primary nurse gave him hydrocodone again before I left. around 2100.

Okay, with all that said, the primary nurse said that I would not make it as a surgical nurse, and I needed to calm down and get some experience under my belt so I dont freak out with the little things. I am hurt by this. I know the importance of around the clock pain management. I know that all these doses were given within the normal time frame. But was I wrong for keeping a really close eye and to learn from the patient the effects of these medications?

Also, my urinary retention patient had his foley removed after a cysto and he hadnt urinated in 5 hours. IV fluids were 125 of NS per hour. PO fliuds were 800 ccs. I know the standard wait is 8 hours before you to call for and order to straigt cath. But, since his was ADMITTED for urinary retention, I was alittle concerned. Lower abd was more distended than earlier, when it was so flat it was almost concave!!! He didnt urinate before I went home, and no one was overly concerned. Later on I heard that the nurses including the primary nurse said I was over reacting. Maybe I was, but is that bad, esp being a student learning the trade of nursing?

Where is the line between attentiveness and over reacting?

Dont flame me too bad!!:rotfl: :rotfl:

[JentheRN05, RN]

I think you will make a fine nurse :) Yes it's important to be attentive. Here's where the nursing standpoint comes in. I only graduated in May, so take this with a grain of salt. Although 2 patients to you probably seems overwhelming, your primary nurse probably had 5-6. You have probably total care on those 2 patients, which is a little overwhelming so I can see that. But you were attentive to notice little things that ARE important. What you did by making a big deal out of it was put a little bug in the nurses hat to keep an eye on them. In a textbook world it would've been VERY important to get the urinary retention man I/O caths ASAP because the threat of infection. In textbook world it would've been extremely important to VERY closely monitor the patient with a gunshot wound and his respiratory depression.

But ..... in the REAL world, we have to prioritize. If your nurse was in the middle of something really important (patient crashing) then I can understand putting these things off. I have personally had to wait 12 hours one time to straight cath a guy because he hadn't peed, and that was because of time restraints. But the fact remains, you put a bug in her bonnet, whether she gets it done now or later it will get done :) So good job.

The respiratory depression guy, although that is quite concerning to a student who has the time to be concerned, pain is what the patient says it is. He is young, and unless his respirs get to 10 or less I wouldn't be overly concerned, but I wouldn't allow him to be overdosed. I would try other methods of bringing his pain down once his pain meds were at their peak and can't be given more.

I hope none of this seems to be a flame, definately not meant to be. Just always keep in mind on clinicals that although textbook suggests one thing, real world only allows so much.

That is one thing I never got in nursing school, so you would be one leg up on others if you learned it now :)

Good luck, and know you did do the right thing. Something to be proud of

[CyndieRN2007]

Thanks for the support. I have just read my post and tried to look at it from another point of view. What I need to do is look at the patient as a whole, not just focusing on the abnormals. I need look at nursing the whole patient and critically think about the abnormals, and what those mean as far as the patients total well being. I love this field, I love the challenge, love how it pushes my mind to the limit, and I cant wait until I start my nursing career!!!

[DONN]

Student4life. You did well to monitor the pt's resp's and report accordingly. Next time look at the orders and see if there is Narcan prescribed for resp's of 8 or less. Ordinarily I wouldnt be overly concerned until such time, then find the RN and have her push the Naloxone......This stuff doesnt come to you overnight but If I were you I wouldnt worry too much. The critical thinking skills are starting to kick in and thats a good thing....

[pinefarmgirl]

heres my:twocents: :typing : there are some nurses who only feel good about themselves when they are able to make fun of someone else. Thankfully, not all of us. I can't tell if you "overreacted", i.e. chasing after her and screaming " aren't you going to do something!!??!!"- but unless you did you were just doing what your supposed to do, learning, or trying to.

As for her, I cannot think of a situation where a floor nurse should ever say to a student: you'll never make it as a ____ nurse- it's wrong. If you are doing something incorrectly, you are there to learn this stuff. The thing she should have done is to tell the instructor her opinion, or the student. I mean your opinion of the best way to correct their misunderstanding, not your opinion of what a failure they are. Unfortunately, this gets said alot.

In my case, a nurse who was supervising me as a student once had said basically nothing to me all day, then 5 minutes before it was time for me to leave, she just exploded in my face. She told me that I would never make it as any kind of nurse, that I was an idiot, and I should quit now and sue my school for allowing me to continue and not teaching me what I should know by then!!!!!!!!! Actually she was shouting. I luckily didn't cry until I was driving home. It took me awhile to realize how wrong she was, but at first I was devastated. Finally I realized what I said above- totally innappropriate!!! Many more nurses that I worked with had said that I was really good at this stuff, but my memory of that went right out the window when this happened.

My class talked about this alot. I think there are just some mean people out there, and some of them ended up nurses. When you are a student and just learning, your confidence is pretty fragile. There is nothing wrong with worrying about your patients- with experience, you will get a better feel for what is usual or not. I would rather see you be very picky than too casual. She probably felt you were making her look bad because she wasn't paying as close attention, which happens when you have 5 or more patients, and the student there only has 2. Pretty lucky by the way- My last clinical rotation I had 4 patients in cardiac step down- thought I would lose my mind!