At 7:30 am I follow the night nurse and my preceptor, whom I'll call "Tiffany," into the room of a patient I'll be caring for today. "Isotonic formula is running through Ms. A's jejunostomy tube at 35 mL per hour but needs to be increased by 10 mL in four hours, up to the target rate of 45 mL. She has TPN [total parenteral nutrition] running through her PICC [peripherally inserted central catheter] line at 70 mL per hour, but that needs to be decreased to 60 mL for 12 hours, beginning at 7 pm." Her report complete, the night nurse asks if I have any questions.
Sure, I think; can we do that again? But I smile, shake my head, and move on to the next task: taking vital signs. Then I'll try to understand the patient's history and surgery before even thinking about target rates and that dressing on her abdominal incision. It's only 8 am, and I'm wondering how I'll survive this shift.
Getting oriented. It's the third week of orientation and only my second day on the surgical step-down unit. Someday I'll remember this as "the day I cried in the clean utility room." My sole responsibility is caring for one of Tiffany's three patients. My morning tasks include taking vital signs every two hours, performing a head-to-toe assessment, reading the patient's electrocardiogram, giving medications, and helping the patient get out of bed.
Two other newly licensed nurses are also working eight-hour shifts during orientation. We're expected to be sharp, confident, and self-sufficient-daunting tasks for a new nurse.
Falling behind schedule. I'm working slowly, still learning how to enter data into the computerized documentation system. It's 10 am before I'm ready to give the patient the medications scheduled for an hour earlier. Tiffany watches as I hang an iv bag containing an antibiotic. I'm unsure of how to work these particular pumps, and I haven't primed an iv tube since nursing school, five long months ago. When I have difficulty disconnecting the tubing to flush the line with normal saline, Tiffany grows visibly disturbed and asks, "What are we raising the rate of the isotonic formula to, and when?"
The unfamiliar floor, the unfinished tasks, and the pressure to perform fluster me. "Seventy milliliters per hour at 12 pm?" Wrong answer. Tiffany looks at me and says, "Courtney, you need to stop being so nervous and start listening. This is not nursing school." The unthinkable happens: I start to cry. I quickly leave the room and compose myself in the hallway.
Reviewing mistakes. I return to work and, just before lunch, review my morning with Tiffany. She notes that my nervousness about using the equipment is affecting my interaction with the patient. She also points out that I seem to have forgotten some of the things I learned in nursing school.
After another discouraging hour of stumbling through my responsibilities, Tiffany and I are in the clean utility room getting supplies when I burst into tears again. (For the record, I am not a crier. I was toughened by four brothers.) She is sympathetic yet firm, reminding me that it's common to feel overwhelmed, but that I can take control of the situation by being better prepared. Go home tonight, she suggests, and read about the patient's surgery. Then she hands me a bag containing needles for drawing blood, tubing, and syringes and tells me to practice my technique as well. "This does get better," she assures me.
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Preparing for another week. I appreciate her guidance but wonder when I'll feel confident enough to perform nursing tasks alone. And when will I look at a patient and think about the state of her or his disease rather than the equipment in the room?
I fall asleep soon after returning home from work and awaken to review my notes from the previous day. I take my medical-surgical textbook off the shelf and open the bag of equipment to prepare for the coming week.
Diary of a New Nurse is a new department chronicling one young RN's successes and difficulties.