My first patient

Last night was my very first night as a GN on my Unit. It was exciting and terrifying at the same time, but it was a HUGE learning experience (which I am sure every shift will be). I figured since we are the highest acuity unit in the hospital, and I am the first GN that we would spend a few nights with me just shadowing and not doing much. I had my little notebook and pen so I could write down all of the information I might need at a later date, and my stethescope (with an engraved puppy dog paw on it thanks to my wonderufl boyfriend)...I was ready to go!!! I sat down with my preceptor to get report, and that is when she told me that she was taking 2 patients and one of them would be mine. I just kind of looked at her while my mind processed the words coming out of her mouth...mine...as in my own patient...as in I am actually responsible for someone tonight...what the heck was she thinking...not on my FIRST day. I think she saw the look of terror in my eyes, took pity on me, and said...don't worry you will be fine and I will be right there with you if you need anything. My mind was going through all of the possibilities and trying to make sense of what I was hearing. I had taken 4 patients for most of my preceptorship, but they were all fairly healthy and stable individuals. Now it is my first day, and I am being asked to take care of one person...why am I so scared. She said she would be right there to help me...what the heck is my problem...why on earth am I having a panic attack. That went on for about 2 more minutes while I tried to get myself calmed down and under control enough so I could take report on my patient. My patient...has a certain ring to it don't ya think :-). Anyways, I finally got myself under control enough to listen to what the day nurse had to say. Pleasant patient, arterial leg thrombus, no pulses below the knee...even with dopplar, arterial infusion catheter with TPA and heparin infusing, also on nitro drip. Goal for the night...keep PTT between 30 and 60, and keep SBP above 140, but below 170 (the doc wanted the BP a bit high to try and help to perfuse the leg as much as possible), pt going to cath lab in morning, so consents and safety checks must be completed. OK....I can do this. I know what drugs he is on and why, I know what has to be done tonight, I have a list of labs a mile long that must be run every 4 hours, but I have 2 peripheral IV's, and one arterial port...I CAN do this!!

We listened to report on the other patient my preceptor was taking, and then went to meet our patients and do the initial assessment. I have NEVER been so scared to talk to a patient as I was last night...my introduction was probably the least confidence inspiring introduction in the history of nursing, but I got it done, and my patient was very pleasant and happy that he was the lucky recipient of 2 nurses for the night (even if one of them was a brand spanking new grad that could barely utter her name ina cohesive sentence). After introductions, my preceptor explained that she was orienting me to the unit and that she would be with me all night following up my assessments with her own. My patient was surprisingly understanding and my preceptor told me to go ahead and start my assessment. I amazingly completed my assessment without losing my ability to speak again, and thankfully other than the cool and pulseless lower leg and oozing infusion port site, my patient had an unremarkable assessment. My preceptor did her assessment while I checked the tubing, connections, and concentrations on all of the IV's. We tucked the patient in with a warm blanket around the cool leg and said we would be back in a few minutes to check in and change the dressing on the infusion port. After we left the room, my preceptor asked me what abnormalities I found in my assessment, and thankfully she agreed completely, so it was then off to assess her patient. Scenario repeated except this time my preceptor was in charge, and I just did a backup assessment so that I would be able to hear the patients rough, crackly breath sounds and artificial heart valve :-).

After the 2 assessments, we talked a bit about how my preceptor organizes her time, and she asked me how I wanted to organize the tasks for the shift. I thought about it and said we should chart our first assessment, get the labs and meds done and then get the dressings changed, and then do the rest of our charting. A word about charting...on our unit, vitals have to be verified at least every hour, more often depending on what kinds of meds the patient is on, or what procedure they had done. We also have to do assessments every 2 hours, so the charting can be monumental. I have not taken the computer charting class for nurses yet (that is tomorrow), so my preceptor did the charting. We did discuss all of our findings, as well as why she does certain things, so I think it actually worked out better that way because I was able to pay attention to what she was doing and why rather than worry about if I was doing something right. In the middle of our charting efforts, we got a call from the lab saying that my patient's PTT was more than 115. I was horrified...why...on my first night...why couldn't my patient cooperate...why does the PTT have to be so high all of a sudden...why after you have been in therapeutic range all day did you have to jump up now? My preceptor was great...she is the best...REALLY...she immediately snapped me out of my downward spiral and said...what should we do? My immediate thought was...high PTT...oozing infusion port site...uh-oh...we need to turn down the heparin. Well, as many of you may know...that is not exactly the right answer :-) (not exactly wrong either though, so I don't feel too bad). Thankfully I fully thought through things before I opened my mouth, and I think she took pity on me because of the silence. She said...why do you think the PTT is that high...well DUH...I know that one...because of the heparin. Right she said, and what do we know about these labs...Oh yeah...I forgot...the day nurse said she drew them from the infusion port that just happens to be infusing the heparin. Right again...so...what should we do? Pull another PTT I asked....DING DING DING...CORRECT!!! Woohoo I am thinking...now if she will just walk me through my entire career like that everything will be hunky dory. So, we proceed to draw more labs from one of the other IV's, and send it down for a STAT ptt...comes back a little bit later, and guess what...PTT is less than 30. YIKES I think...why me...now it is too low and there will be more thrombi to deal with...yikes...what now. Well, that is exactly what my preceptor said...what now? Well, in my head I say...we have a double checked PTT, a patient that needs to be within a certain range, and we are not within that range...do I need more info? No...I can implement now...what implementation do I perform? Up the heparin a bit of course :-)...DING DING DING...correct again!!! I felt pretty good, even though we had to talk about it a bit before I figured out what to do. I think with time, it will come a bit easier, and for now, my patient was back in therapeutic range (we sent 2 more PTT's in the next 4 hours to be sure).

The PTT debacle was in a way the highlight of my night. Of course I got to perform lots of skills (central line dressings, suctioning vent patients, hanging tube feeds, antibiotics, and various other drips, eye care for a patient with ulcerated sclera, and more lab draws than I though possible), I learned about our charting system, and our monitors, and tons of other things, but in the end, the critical thinking is what this whole job is all about. There is a saying in my unit that "we get paid for what we know, not what we do", and I learned within the first 3 hours of my very first night on the unit that this saying holds very true. I have spent most of nursing school going through the motions of learning how to critically think, and now I need to learn how to put that in to practice in my day to day career. Thankfully I am now part of an AWESOME team of nurses that will spend the next 9-12 months training me and mentoring me and helping shape me into a great CSU nurse.