What I've learned in my first year as a nurse
It's weird to think that the one-year anniversary of my nursing school graduation is right around the corner (this weekend, really). I've learned quite a few lessons in that year, and god knows I've got quite a few more to learn.
So, the big lessons?
1. If a patient says, "I heard something pop, and then..." whatever follows is probably not going to be good, and you might want to start thinking about calling for help once they get the rest of the sentence out. This goes doubly for patients who are 24 hours after open heart surgery... with chest tubes. You might not need the help, but at least start thinking about it.
2. Ask for help when you need it. It can be hard to step back and ask yourself "what can I have someone else help me with" when you're completely buried, but it's important. If you're overwhelmed, it's better to ask for help before the last hour of your shift. When you need help, think of specific tasks you can ask someone to do: Can you get vital signs on so-and-so? Can you do two chart checks for me? And never ask someone to do a chart check for you, then go out and smoke a cigarette instead of doing your work. It tends to piss people off.
3. Also, if you're caught up, step back and see who's buried and might need that chart check done for them, a set of vitals or an antibiotic hung. You never know when you'll need the favor returned and someone else will save your ass when you're floundering. And sooner or later, everyone flounders. Nursing IS a team sport.
4. Listen to your patients. They might be talking to you about their wife that died nine months ago, and that may not be a life or death matter to you, but it is to them. Let them talk. Listen. They probably are saying something important underneath all that. At the same time, know how to carefully extract yourself from a conversation so you can get your work done - I'm still working on learning this. Equally importantly, if a patient's telling you "I'm going to die," you'd better step back and listen to that too. It might be nothing, but do you want to assume it's nothing and be wrong? Take a look at their trends - vitals, urine output -and step back and take a look at the patient. How's their color? Is their respiratory rate normal, but irregular, or are they using their abdomen to breathe? If nothing else, keep a watchful eye on a patient who says this, even one who you think is crying wolf. CYA.
5. Flip side: Know when your patient is bullshitting you. This can be tough. Remember... although we all want our patients to like us and think we're the best nurse EVAR, we're not there to be a patient's friend. We're there to help them get better, and sometimes, you may have to say things they don't want to hear - and man, can that be hard. Just be respectful and understand that very rarely is it about you. Be willing to stand behind what you've said, though, and reflect upon how you could've handled something better.
6. Know whose assessments you can and cannot trust, and ALWAYS assess a situation for yourself. You may get report on a patient and hear that his or her lungs are clear, and then you might walk into their room and find their lungs are full of fluid. Does it mean the nurse before you was wrong or careless? Maybe. Maybe not. Does it mean that something changed suddenly? Maybe. Maybe not. Does it really matter? Nope. Just deal with the issue as best you can. Things can happen suddenly, and in the moment, it's not really important who might be to blame. You hear/see what you hear/see. Trust your assessment. Trust your gut.
6. Standing orders are your friend. Know them. Use them. Check them before you call a doctor at 3 AM.
7. Speaking of calling doctors at 3 AM... Sometimes you're going to have to. Be darn sure that you call the doctor who's actually on call... And be exceedingly grateful if the one you call on accident doesn't rip you a new one. (And trust me, I am. Doubly grateful that he gave me the order I needed without hesitating, so I didn't have to call yet another surgeon in the middle of the night. Oops.) When you call a doctor in the middle of the night, be prepared to give him or her the whole story as it pertains to the current situation. If a patient is in a new exciting cardiac rhythm (exciting, right...), be ready to tell them if they have a med ordered that you could give early to help with it. Be ready to tell them if they had a med that might've caused it! Do they need to know that patient had a bowel movement at 3 AM? Only if you think it's related to the symptoms? Hurray for vasovagal reactions! Also... remember that the docs are human. If they yell at you, they yell at you. Get over it. (Easier said than done.)
8. Cough and deep breathe! This goes for nurses as well as patients. ;)
9. Family's important. When they call at 6:30 AM and you're about to give report, talk to them. I find it frustrating, but I have to remind myself just how I would feel if it were my family member. Also remember that some families are supportive to patients in their recovery, while others simply aren't. Do the best you can to support the patient and their family, but sometimes that means gently suggesting to the family that they let the patient get a little rest!
10. Before giving a med, ask yourself, "Does this make sense?" If you know the sleeping pill dose that is normally given is 5 mg, and you see 10 mg in the med administration record... STOP AND THINK. Check your orders before you give it, even if you're horrifically busy. Look at how old the patient is. Ask the patient if they've ever taken X med before.
11. If you're uncertain about something you're about to do, ask yourself "what is the worst possible consequence of this?" Giving Lasix (a diuretic) to a patient who was on major BP support earlier in the day, whose blood pressure is okay, but still on the low side whose urine output is also on the low side? Think twice - do you want to be chasing that BP all night? What could you do instead? What other clues are you getting from your assessment? How do their lungs sound? Full of fluid? Maybe that Lasix is a good idea, after all! Similar questions: That patient with inoperable stage 4 metastatic lung cancer... do you really need to get her out of bed when she's sleeping soundly and weigh her, or will a bed weight do? That 50 year old patient who just had open heart surgery - just because he doesn't want to get out of bed and get weighed, does that mean he shouldn't? Is he stable? Get his butt out of bed!
12. This is my own personal demon, and I'm sure that not all new nurses deal with it. Learn to have a little faith in yourself, and trust your assessments & nursing judgment. Every single time I've questioned myself, I've been right and didn't really need to ask for anyone else's opinion. I'm getting better about this. I recently had a patient go downhill, fast, and we called a Rapid Response Team on him. One of the hardest things I've ever done was push past the other 15 people in the room to the head of the bed and say, "He's my patient, and this is what's going on with him - this is what I have assessed." I had a moment of extreme disbelief when I grabbed the BP cuff and took a manual BP on him in the middle of the chaos. It's such a simple, simple nursing assessment/action, but in nursing school, I struggled with believing that my BPs were accurate and that I was hearing things correctly. (They were and I was.) My hands were shaking until 4 AM, and I felt like I was going to throw up while I was on the phone with the surgeon getting orders... and, god help me, asking for specific things (sooo, how about some albumin for that BP that's in the toilet, doctor? And a heparin drip, just in case he really is throwing clots to his brain?). I'm sure he could hear my voice shaking, though I am secretly hoping I sounded better than I felt, at that moment. The part that's surreal? I usually suggest the right things... and our surgeons WELCOME that. I can't begin to say how lucky I am to work on a floor that has that type of relationship with our surgeons. Once in a while, I even get a "That's a great idea - let's do it." I have to give the other nurses on the floor credit too - they've taught me what to ask for.
I'm still learning every single day that I walk onto the floor... both professionally, and personally. I still have a lot to learn. I've come a long way in a year, though, and I hope to continue to grow as a nurse. Now, if I can just take my own damn advice and stop second-guessing myself...
So, the big lessons?
1. If a patient says, "I heard something pop, and then..." whatever follows is probably not going to be good, and you might want to start thinking about calling for help once they get the rest of the sentence out. This goes doubly for patients who are 24 hours after open heart surgery... with chest tubes. You might not need the help, but at least start thinking about it.
2. Ask for help when you need it. It can be hard to step back and ask yourself "what can I have someone else help me with" when you're completely buried, but it's important. If you're overwhelmed, it's better to ask for help before the last hour of your shift. When you need help, think of specific tasks you can ask someone to do: Can you get vital signs on so-and-so? Can you do two chart checks for me? And never ask someone to do a chart check for you, then go out and smoke a cigarette instead of doing your work. It tends to piss people off.
3. Also, if you're caught up, step back and see who's buried and might need that chart check done for them, a set of vitals or an antibiotic hung. You never know when you'll need the favor returned and someone else will save your ass when you're floundering. And sooner or later, everyone flounders. Nursing IS a team sport.
4. Listen to your patients. They might be talking to you about their wife that died nine months ago, and that may not be a life or death matter to you, but it is to them. Let them talk. Listen. They probably are saying something important underneath all that. At the same time, know how to carefully extract yourself from a conversation so you can get your work done - I'm still working on learning this. Equally importantly, if a patient's telling you "I'm going to die," you'd better step back and listen to that too. It might be nothing, but do you want to assume it's nothing and be wrong? Take a look at their trends - vitals, urine output -and step back and take a look at the patient. How's their color? Is their respiratory rate normal, but irregular, or are they using their abdomen to breathe? If nothing else, keep a watchful eye on a patient who says this, even one who you think is crying wolf. CYA.
5. Flip side: Know when your patient is bullshitting you. This can be tough. Remember... although we all want our patients to like us and think we're the best nurse EVAR, we're not there to be a patient's friend. We're there to help them get better, and sometimes, you may have to say things they don't want to hear - and man, can that be hard. Just be respectful and understand that very rarely is it about you. Be willing to stand behind what you've said, though, and reflect upon how you could've handled something better.
6. Know whose assessments you can and cannot trust, and ALWAYS assess a situation for yourself. You may get report on a patient and hear that his or her lungs are clear, and then you might walk into their room and find their lungs are full of fluid. Does it mean the nurse before you was wrong or careless? Maybe. Maybe not. Does it mean that something changed suddenly? Maybe. Maybe not. Does it really matter? Nope. Just deal with the issue as best you can. Things can happen suddenly, and in the moment, it's not really important who might be to blame. You hear/see what you hear/see. Trust your assessment. Trust your gut.
6. Standing orders are your friend. Know them. Use them. Check them before you call a doctor at 3 AM.
7. Speaking of calling doctors at 3 AM... Sometimes you're going to have to. Be darn sure that you call the doctor who's actually on call... And be exceedingly grateful if the one you call on accident doesn't rip you a new one. (And trust me, I am. Doubly grateful that he gave me the order I needed without hesitating, so I didn't have to call yet another surgeon in the middle of the night. Oops.) When you call a doctor in the middle of the night, be prepared to give him or her the whole story as it pertains to the current situation. If a patient is in a new exciting cardiac rhythm (exciting, right...), be ready to tell them if they have a med ordered that you could give early to help with it. Be ready to tell them if they had a med that might've caused it! Do they need to know that patient had a bowel movement at 3 AM? Only if you think it's related to the symptoms? Hurray for vasovagal reactions! Also... remember that the docs are human. If they yell at you, they yell at you. Get over it. (Easier said than done.)
8. Cough and deep breathe! This goes for nurses as well as patients. ;)
9. Family's important. When they call at 6:30 AM and you're about to give report, talk to them. I find it frustrating, but I have to remind myself just how I would feel if it were my family member. Also remember that some families are supportive to patients in their recovery, while others simply aren't. Do the best you can to support the patient and their family, but sometimes that means gently suggesting to the family that they let the patient get a little rest!
10. Before giving a med, ask yourself, "Does this make sense?" If you know the sleeping pill dose that is normally given is 5 mg, and you see 10 mg in the med administration record... STOP AND THINK. Check your orders before you give it, even if you're horrifically busy. Look at how old the patient is. Ask the patient if they've ever taken X med before.
11. If you're uncertain about something you're about to do, ask yourself "what is the worst possible consequence of this?" Giving Lasix (a diuretic) to a patient who was on major BP support earlier in the day, whose blood pressure is okay, but still on the low side whose urine output is also on the low side? Think twice - do you want to be chasing that BP all night? What could you do instead? What other clues are you getting from your assessment? How do their lungs sound? Full of fluid? Maybe that Lasix is a good idea, after all! Similar questions: That patient with inoperable stage 4 metastatic lung cancer... do you really need to get her out of bed when she's sleeping soundly and weigh her, or will a bed weight do? That 50 year old patient who just had open heart surgery - just because he doesn't want to get out of bed and get weighed, does that mean he shouldn't? Is he stable? Get his butt out of bed!
12. This is my own personal demon, and I'm sure that not all new nurses deal with it. Learn to have a little faith in yourself, and trust your assessments & nursing judgment. Every single time I've questioned myself, I've been right and didn't really need to ask for anyone else's opinion. I'm getting better about this. I recently had a patient go downhill, fast, and we called a Rapid Response Team on him. One of the hardest things I've ever done was push past the other 15 people in the room to the head of the bed and say, "He's my patient, and this is what's going on with him - this is what I have assessed." I had a moment of extreme disbelief when I grabbed the BP cuff and took a manual BP on him in the middle of the chaos. It's such a simple, simple nursing assessment/action, but in nursing school, I struggled with believing that my BPs were accurate and that I was hearing things correctly. (They were and I was.) My hands were shaking until 4 AM, and I felt like I was going to throw up while I was on the phone with the surgeon getting orders... and, god help me, asking for specific things (sooo, how about some albumin for that BP that's in the toilet, doctor? And a heparin drip, just in case he really is throwing clots to his brain?). I'm sure he could hear my voice shaking, though I am secretly hoping I sounded better than I felt, at that moment. The part that's surreal? I usually suggest the right things... and our surgeons WELCOME that. I can't begin to say how lucky I am to work on a floor that has that type of relationship with our surgeons. Once in a while, I even get a "That's a great idea - let's do it." I have to give the other nurses on the floor credit too - they've taught me what to ask for.
I'm still learning every single day that I walk onto the floor... both professionally, and personally. I still have a lot to learn. I've come a long way in a year, though, and I hope to continue to grow as a nurse. Now, if I can just take my own damn advice and stop second-guessing myself...