My First day.....

My first post, kinda scary, I have been trying to decide what to go with, I think I will talk about my very first day as a nurse. I was a new grad who had precepted in the unit I get hired into. The unit was one that was high stress and had an extremely high turnover rate. My very first day as a nurse, my new nurse manager asked if I would not mind taking just one patient. This patient was post op day 3 from a VSD and would have been moving to the floor except all of the beds were full out there. So my enthusiasm for nursing overtook my common sense (this would set the precedent for my entire nursing career), and I said yes. She assured me that my preceptor would be able to help me with any questions or concerns.


All was going well until 915, when the patient started acting confused and talking out of her head. My preceptor was busy admitting 2 patients who had returned from surgery within 30 minutes of each other, so I called the nurse practitioner and told her that I think something was wrong with my patient, not sure what, but the patient just didnt look right. The NP said she would be back there in a minute. Upon arriving, my patient is now breathing like a guppy and I am feeling a bit guppy-ish too, I put her on a Non Rebreather mask and turned the O2 up to 15 liters.

"Have you drawn an ABG yet?" she asks.
Me standing there, looking slightly perplexed, "umm no".
"Well dont you think you should get one, you obviously think this patient is hypoxic since you went from no O2 to 15 liters" she said.
"Umm doesn't respiratory therapy have to get those?"
"The patient has an art line, don't they?"
"No it was taken out on anticipation of transferring out."
"Well page respiratory, now and get a portable chest"

So I page respiratory and x ray, and they come and get a gas and a film. The PO2 is 41 and this is after the patient has been on 100% O2 for a good 10 minutes. We page or anesthesist to intubate and notify the surgeon, who is in another case right now. The xray (according to the NP) shows an enlarged mediastinum and Pneumothorax, now I have no idea what she just said, but I do recognize the next words out of her mouth, "we are going to need a intubation roll, the crash cart at the bedside and you need to set up for a chest tube." Even though I recognize them, I had no idea what I needed to setup for a chest tube, I ask her to help me and we get it set up before the anethesist arrives. We also hung some dopamine because her blood pressure was soft and we apaced her using her epicardial pacing wires at 80.

The anethesist asks me to push 120 of succs and 20 of etomidate, I just look at him, I did not realize that I should already have the drugs. So I run and try to get them out of our pyxis, and my number does not work yet. I hunt down someone else to get the drugs. I come back apologizing while trying to pull up the meds, he is BVMing the patient, who at this point doesn't really look like she actually needs the drugs, but I push them in anyway. After successfully intubating the patient, looking at the post films, and talking to the surgeon, he decides that this patient is going to need a triple lumen and a swan. I explain to this dr (thank goodness it was one of the nicest drs I have ever met), that I had been a nurse exactly 3 and a half hours, period, and while I did not mind helping with this stuff, could he keep that in mind, and humor me if I was a little slow. Setting up a "4 way" (the device used to monitor arterial pressure, CVP and PA pressures) was something I could do in my sleep considering I had precepted as a nursing student here and this was a task that got delegated to me ALOT.

First day precepting 0700:
"Hey have you ever set up a 4 way" says Old nurse #1.
"No" I say.
"Here let me show you how it is done" she syas.

First day precepting 0800:
"Hey have you ever set up a 4 way" says Old nurse #2.
"Not by myself" I say.
"Here, I will watch you and help you out if you need it," she says.

First day precepting 0830:
"Hey have you ever set up a 4 way" says Old nurse #3.
"yes" I proudly say.
"Can you do it for me, I kinda got my hands tied" she syas.
From then on out, that became my specialty once word got around that i could do it, but i digress, back to the story.

So the patient is now intubated and I have the 4 way set up, but no clue what I need to get for the art line, central line or swan. My preceptor is to the point where she can help out and shows me what I will be needing before having to get back to her patient who just dumped 500 ccs blood in the chest tubes. I help the doc and everything goes with out a hitch, except I hook up the PA ports to the CVP port, but that was easilt remedied. The practitioner put in the art line without a problem. At that point the Surgeon has just made it to the floor, he also is one of the nice ones. He starts asking questions and I tell him what I know to the best of my abilities, he looks at the xray, and says that the patient needs a chest tube and also needs to go back to the OR. I also tell him that "I have been a nurse for only 4 hours now, and while I am not scared to help you, I want you to be aware. (while nice, he is also known for his temper tantrums if provoked)." He says ok and walked me through exactly what I needed to do. The chest tube got put in, the swan, art line and central line got placed, and the patient was intubated and heading back to the OR, and I had done it with minimum help (not because they were not willing, there were just alot of sick patients that day and they were short) and all within the first 1/3 of my shift!

After I broke down and cried because the NP came by and said "You did a really great job for a new nurse, but the fact of the matter is that the patient does not care if you have been a nurse for 2 minutes or 30 years, if they are dying, certain interventions need to be made. You chose to work in this unit, and you are expected to be able to anticipate what interventions need to be made when certain symptoms are present, this is LIFE or DEATH we are talking about. Just remember that", I took a deep breath, got some of the nurses to help me with my charting and waited for my patient to return. The rest of the shift went without a hitch, the patient came back from surgery (a pericardial window after the vsd patch leaked and caused a tamponade), and did well, went home after 6 weeks in the hospital. The practitioner told me months later, I never should have had that patient, VSDs have an enormously high complication rate, and I survived with more confidence in myself than Most after their first days. Talk about orientation by fire. Imagine my surprise when I returned to work the next day with a preceptor........