clinical

  1. Hey guys,

    This is Zach. Well first quarter clinicals are almost over but I feel horrible. I have a new patient who has Parkinson's (doesn't talk at all) and I just am realizing how inept I am.
    Just getting him cleaned up and to breakfast is the biggest chore! But I have to do assessments and all stuff. I did an abdominal assessment today and listened for bruits and thought, "I wouldn't know even if I heard one"..I only think I heard bowel sounds that's it. There was a lump and I had my instructor look at it..I thought it was stool and we thought maybe it was a distended bladder so I'm gonna check tomorrow to see if it's still there. But how do you know it's that and not something major? See, things like this make me think I'll never be capable of doing meaningful assessments.
    Cleaning him up is such a chore as it takes forever to get him to help you turn in bed. When I finally got him up, I had another student with me and the instructor and his undewear felt wet as we put it all the way on him. How could that be since he didn't even wear it yet? I thought maybe a wet cloth had made it wet. The other student didn't feel it wet...I mean sometimes I wonder if my imagination plays tricks on me. It could have been sweat too.
    Basically, I want to be a nurse..I want to take care of patients. But I feel at this point I am not adding anything beneficial to the patients. I mean I have trouble doing basic things and to do assessments too, it's a nightmare. Any words of advice??

    Z

    P.S. When you do pericare on the bottom, can you just roll to one side and clean it all or do you have to roll on the other side too. With patients hard to turn, it seems better just to try to clean it all good while on one side to expedite the process and not have them do all this tossing and turning.
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  2. 13 Comments

  3. by   stressa26
    I used to feel the same way you do, and I still do everytime I do part of my rotation.

    I am telling you the honest to God truth when I say this, it does get easier and better. Just keep going and don't give up, k?

    p.s. do pericare on one side. If you get them on their side far enough, you will be able to clean it all.

    Sincerely, Stephanie
  4. by   peaceful2100
    Zack Hi there.

    I was laughing and feeling bad for you at the same time.

    I been exactly where you are at now and the best thing about this board is that we get each other through the rough spots. Like you a simple chore for the nurse or nurse aid would be a long chore for me. My assessment skills were horrible. Well Zack I started laughing because now most of those things are not long chores for me anyymore. I was looking back and reflecting about how you are feeling right now. For me I have improved and it is getting much, much easier I am starting to learn more and more and doing an assessment is becoming much easier. We are in shcool learning it will come to us with patience and practice. Even when we do become nurses we still will not know it ALL. My instructor who has been a nurse for 30 years says she learns something new and different everyday and that is what we must all keep in mind. We are in a profession where the learning will be lifelong until we decide we are through with the profession.

    You will soon begin to see that your confidence skills will raise higher and higer each and every clinical day. I am so glad I did not give up after one semester from feeling like I was not doing anything good and would not be able to do this. A very good instructor told me to wait a while and I did. It took a while but it is starting to come together and starting to pay off.

    SMILE
  5. by   GPatty
    Zach~
    You are not inept! You are a student! Still learning and discovering YOUR ways of doing things! Everything you say will soon fall into place and you will no longer feel this way. Hang in there and believe in yourself. Your skills will soon come....
    Julie
  6. by   tariet
    Hang in there Zach. It does get better. Or should I say, YOU will get better. The more experiences you have the better your going to get at dealing with them. I'm in my final semester and the nursing aids can still do my patient care better and faster than I can. But looking back I've gotten 100% better than I was first semester. Don't be to hard on yourself and remember to review what you learn after every clinical. Things will get easier I promise. Tariet
  7. by   NICU_Nurse
    Hello!!!!! Stop freaking out! ;>) And stop being so damn hard on yourself!! It's a total cliche, but we ALL felt that way when we were in your shoes. It's overwhelming! I have faith in you, however. You can do it, grasshopper!!!!!!!!!!!!!!!!!!!!!!!!! Now. First things first. If you're unsure how to do a physical assessment, I wrote a TERRIBLY long post about this to another poster a while back; if you search my name, you'll find it in my posting history. If you're short on time, email me if you want it, and I'll send it to you instead.

    When I first started school, we did a nursing home rotation the first semester. With me and ANOTHER STUDENT it took us an hour to do a bed bath on an alzheimer's patient! AN HOUR!!!!! ROFLROFLROFL! ;>) I would have quit nursing school if it hadn't gotten better than THAT! We bathed her, and she had little bits of food stuck in every wrinkle, from head to toe, and how that happened I"ll never know. We got her cleaned up and ready to put her clean clothes on, and I went to the chair, picked up her CLEAN CLOTHES, and we put them on her while she was in her CLEAN BED WITH CLEAN SHEETS. I go to adjust her clothing after it was on, and I'm like, 'What the-..." There were kernels of corn EVERYWHERE!! CORN!!!!!! Where the hell did it come from? The sky? We STILL can't figure it out!! There was corn all over the sheets, and all over her clothes, and we'd just bathed her nude body from head to toe and brushed her teeth and everything while she was lying in a bed we'd JUST CHANGED THE SHEETS AND BEDDING ON!!!!! Just remember this next time- and don't say I didn't warn you about those veggies!!!!!! Thank god it wasn't carrots! Anyway. Don't feel bad about taking a long time to complete your tasks; you pick up speed really quickly from semester to semester. As far as the pericare goes, always, always, ALWAYS get a partner if the patient is unable to move themselves and you're unsure. Don't hesitate, otherwise you might end up with your patient on the floor! DON'T EVER FEEL BAD ABOUT ASKING FOR HELP. You're students, that's what you're there for: team work. As a nurse, you should feel the same way. People might not be able to help right away, but they will eventually. Or offer your help to others- they might be afraid to ask. If you have a partner, I find it easiest to tell the patient that you're going to roll them to so and so, and for them to hold on to the rail if they can. Using the draw sheet if you need to, roll them as faaaaaaaaaaaaaaaaaaaaar as you can onto their side towards your partner and have your partner use one hand between their shoulderblades and another hand on their hip to keep them from rolling back and then you should have wide access to the peri area to clean them up. This technique is good for diaper changes and bedding changes too (just put the diaper or bedding underneath them, then have your partner 'push' them to YOU, rolling them as far towards YOU as possible, and they can pull the diaper underneath the patient from the other side).

    And for the abdominal assessment- a bruit is simply an abnormal sound. It could be one of many things, as far as I'm aware, but you'll know it because it's not supposed to be there!!!! Our first semester was all about learning the healthy patient so we could recognize the unhealthy one. Is there supposed to be a cardiovascular sound audible in the abdomen? No, so as long as you can distinguish bowel sounds, you'll know how to tell the difference. if you're still unsure, take some time to listen to your own bowel sounds one evening. Just lie down, and listen in all four quads for a couple of minutes. Try it when you're hungry, when you've just eaten...you're healthy (I'm assuming!), so these would be typical of normal, healthy bowel sounds. Listen to your mom, your girlfriend, your dog, whoever...these are the only sounds you should hear coming from the abdomen. Anything else is abnormal. A bruit, if there was one, could have been indicative of an abdominal aortic aneurysm, which would also possibly be seen with a PULSATING abdominal mass. I'm guessing this guy didn't have that. ;>) You were right on wondering if it was a distended bladder or fecal mass. You asked how to tell th difference? Process of elimination!! Let's start with bladder. You would evaluate his bladder habits- is he continent? If so, when was the last time he voided, and how much? Look at his intake and output- do they balance? Has it been a while since he voided? Or is he incontinent? How often are you changing the wet diapers? Does he have any known urinary problems? He could be retaining urine despite being able to urinate (as happens with diabetics, or in the case of a UTI for example)...this could be answered by doing an in and out cath after he's voided and seeing how much urine was left in the bladder. If you suspect a fecal mass, why would you suspect that? When was the last time he defecated? What are his bowel sounds like? Etc. Go one-by-one through all of the possibilities you can come up with, and if you STILL don't know, ask your instructor or the nurse.

    "You know, I noticed an abdominal mass in Mr. so and so when I did his assessment; he seems to be voiding and eliminating regularly, and I'm stumped as to what it could be. You know us students, always questions, questions, questions...do you have any idea what it could be?"

    The only bad question is the one that goes unasked. ;>)

    In the meantime, I found two websites you might want to go to to check out. They include abnormal cardiovascular sound files, as well as normal sounds (the normal, lub-dub sounds you're probably familiar with). You can listen to them on your computer and learn to differentiate between what is to be expected in your 'healthy' patients and what should cause you to be concerned. Just a thought. They have web sites like these for breath sounds too, and they're a huge help when you're learning to do assessments, because they teach you the difference between crackles, pleural friction rub, etc. The more you listen, the more you learn!!! Good luck to you, and if I can help in any way, feel free to email me. I'm on yahoo messenger as 'bandaidbimbo', and I've already given you my email address, so hopefully you'll glean some shred of assistance from this drawn out post. ;>) Happy nursing!!!!!!! And hang in there! You're doing MUCH MUCH MUCH better than you think you are!!!!!!!!

    http://www.wilkes.med.ucla.edu/Rubintro.htm
    http://sprojects.mmip.mcgill.ca/MVS/MVSTETH.HTM
    Last edit by NICU_Nurse on Aug 28, '03
  8. by   NICU_Nurse
    I went ahead and found that assessment post for you...hope this helps a bit! Here it is:

    I hate to say this, but it's so neat to be out of that first semester and have those jitters gone (only to be replaced by NEW jitters, but you can't win, can you?)!! :> ) Here's what I do, not just then, but now when I go to clinicals. First of all, take lots of deep breaths and picture stress and anxiety and fear as 'red steam' and calmness and wisdom and strength as 'blue steam'. Breathe out red, breathe in blue. I have been known to secure myself in the corner of the supply room to do some creative visualization in a pinch!!! Don't be embarrassed...you will be clear headed and focused, which will allow you to be the best nurse you can be. Secondly, realize that even the most experienced physicians and nurses started out just like you- scared to death not knowing what the hell they were doing. Lots of people just don't admit it- I'm one that does. I admit that I am a student. I have a limited amount of knowledge. I don't know everything. I hardly know anything. Tip of the iceburg, as far as nursing is concerned. What I do know is this: I am a great person. My heart is in the right place, and my mind will follow. If I am in doubt, I will hesitate and ask rather than risk harm to my patients, no matter how trivial or small it may seem. I forget things. I have used these IV pumps for two years now, and occasionally, I STILL forget how to program them. NO problem. I just ask. With a big smile and a wink. Humor helps. A LOT. So does charm. Lay it on thick. "I know I should probably know this, but you know us nursing students- totally worthless. *wink&smile* Would you mind showing me/reminding me/answering a question for me? I'd really appreciate it." "I feel comfortable asking you this, because you're so with-it and seem so knowledgeable..." Etc. Okay. Next step? When you go into a patient's room, or to their bed, remember ALWAYS that they are a person just like you. They are a son or daughter. They have a sister or brother or wife or kids. They may have a job, they may have experienced loss, they may be broke, they may have a heart of gold, they may be misled or confused...they're all people, just like we are. Exhale, smile, walk into the room, make eye contact. Connect with them. They are not a bunch of machines with a person thrown in there...they are a PERSON FIRST, with a bunch of machines and tubes to keep them company. ;> ) Introduce yourself (again, even if you've met them before), ask them how they're feeling this morning. Any complaints? Did they get some sleep last night? I always make a little joke and smile my butt off to get them 'on my side', if you will. "So, did you manage to eek out an hour or two of sleep with all of these crazy people running in and out of your room all night?" I smile and laugh, maybe touch their arm if it's appropriate, all the while I'm connecting with this person. Pretend they're your favorite neighbor. Your best friend's dad. Whatever. Already, you're gathering important information here- if they don't respond, why not? Are they just lying there in a coma? Are they lying there with an irritated expression and purposely ignoring you? If so, what could be the reason for that? ARe they answering your questions and perhaps complaining about no sleep because of pain? Great! You just got pertinent info for your assessment. Patient is alert and oriented; c/o abdominal pain. Now, you want to be as specific as possible. (We always do an opening, head-to-toe narrative every morning.) They just said their stomach is hurting. Okay, how badly? Can they rate it? Can they describe it? Can they point to it? Take a look at the abdomen. Put on a pair of gloves, lift the gown, look at the abdomen. Wow, it looks okay to me...let's see... gently palpate (as appropriate- in some cases you won't do this, but you decide)...he moans as you barely touch his left upper quadrant. Okay, great! More pertinent info! Pt. c/o sharp, stabbing abd pain in LUQ rated 9 on a 1-10 scale. Tender upon light palpation. Or, you may see that their dressing is soaked through with blood...upon further inspection, you might find that their stiches have come apart and their abdomen is gaping open. Whatever- it will vary from patient to patient, but you get the idea. Chart it. I used to use looseleaf, then copy it over to the chart once it was approved by whoever (instructor, RN). The best thing to do is a head to toe. Start at the head. Go from top to bottom...look at the eyes...expression on their faces (smiling? Frowning? Facial drooping to one side?). Are they sweating? Anything unusual? Do the whole face. Great. Now move on to the neck...anything wrong there? Carotid pulses intact? Jugular vein distention? Nothing wrong? Look thoroughly, then move on down. Chest. Listen to the apical pulse. What does it sound like? Strong? Rhythmical? Skipping beats? Fast? Weak? Make a note of it. Listen to the breath sounds. Note them. While you're doing this, check out their skin. Scars? Wounds? Bruises? Anything wrong? Listen to the abdomen. Bowel sounds? Feel it. Tender? Soft and squishy? Does it look swollen? Is the skin tight and shiny? Check out the arms. Have them grip your fingers and pull with both arms at the same time. How is their grip strength? Weak? Nonexistant? Normal and strong? Can they lift their arms up? Move them around? Great. ROM is intact in upper extremities. Move to pubic area. Do they have a foley catheter? Is it unclamped? Draining? Kinked? Unkink it. Look at the collection chamber. Is there urine in it? Bloody urine? Clear yellow urine? Amber urine with clumps? Write it down. What about the pubic area? Is it clean? Blood present? Does the area around the foley look swollen or irritated or otherwhise abnormal? Note it. You get the idea. Simply move head to toe. Don't be afraid to use your flow sheet, if you have one. I have often used it to double check that I haven't forgotten anything. Don't worry if you have to go back and do something. I always say, "Alright, now, I appreciate you being patient becasue as you know, nursing students don't know a whit about nursing." winkwink. Of course, don't say this if you think they're going to freak out. Improvise, say what you think will be appropriate. I use a lot of Southern charm and thank them furiously for being patient with me, because when I started, I'm sure I took a reaaaaaaaaaaaaaally long time to do my assessments!!! :> ) Do the head to toe. If you haven't done this by the time you're done, once you finish the head to toe, go back to the equipment. Does he have an IV? A heplock? Where is it? What does the site look like? Chart it. Hep-Lock to left anterior hand; dressing clean and dry, site shows no signs of erythema/infiltration/irritation. Is the heplock attached to tubing and an IV? Okay. follow the tubing up to the IV. Look at the bag, get the drug and dosage (10 grams, whatever). Then look at the pump, get the drip rate. Chart it. 0.9% NS IVF infusing at 120 cc/hr to left anterior hand. Is there more than one? Follow each tubing and chart it. One at a time. ONE AT A TIME!! Don't panic. Break it down into approachable bits. When you're done, ask if you can get anything for the patient. Ice? Water? Tell them when to expect breakfast, if they're allowed to eat. If not, tell them why they can't eat, and then tell them what you CAN do, ie, get them as much juice as they want, or get them as much ice and water, or only ice chips, or whatever. Let them in on the plan for the day. Okay, this is what I'm going to do...I am going to go write all of this good stuff down. I'll bring some apple juice and an extra blanket for you. We're going to get you out of bed for a bit and get you cleaned up, and you can brush your teeth like you asked me about before. While you're up, I'll change the sheets and all on your bed. After that, we'll see what else we can do for you this morning, okay? Then go do your thing. You get outside and you forgot something? No problem. Run back in and say, whoops, I forgot one thing...let me just check your eyes real quick...great, thanks Mr. Jones. I'll be back in just a bit and we'll get started. Big smile. Don't freak. ;> ) YOu'll do great!!! I find that talking to them is really crucial...it puts us BOTH at ease. I talk to patients who don't even respond! I sing to patients in comas, I talk soothingly to patients who are disoriented, I talk to the walls if I have to!! ;> ) I find that if they're alert and all, explaining what I'm doing helps also. Okay, now, I need you to flex your feet up like this for me...great...now what do you feel when you do that? Nothing? Any discomfort? Great. We do that because it helps us find out if you're developing any complications from being in bed so long...we want to keep you healthy so you get get out of here before the dawn of the next century!! You get the picture. You'll do wonderful. You will, I promise. You'll sweat, you'll freak, you may cry from panic, but you might not. Either way, you'll do a hell of a lot better than you think you will! Take stuff with you- lists of parameters, lists of drugs, calculation formulas, lists of vocabulary that you cant remember, whatever. Make a binder, and each semester, add charts and whatnot to it. It'll be your greatest resource. Copy coma scales and things on figuring caloric need and IBW and anything else you might need. A paper ruler to help figure out wound size. Things like that. Put a zipper pouch in there and throw things in that you can use. Paperclips, safety pins, a sharpie marker, small roll of tape, measuring tape, extra penlight, extra black and red pens, etc.




    Sorry it's so long- I'm a lonely girl! ;>)
  9. by   NICU_Nurse
    Here is a site devoted to breath sounds. Last post, I swear! ;>)


    http://www.rale.ca/Recordings.htm
  10. by   GPatty
    Hey Zach!
    I had almost forgotten about the post from KristieWhite about assessments.
    It was for me! I was sooooo scared when I first started and she reasurred me with that post. I printed it out and I carry it with me when I go to clinical. Try it!
    I don't think I ever said,"Thanks Kristie!"
  11. by   sundance
    Hi, Zach.
    When I did my first clinical for RN training, I had been an LPN for 14 years. However, I hadn't worked day shift for most of that time and hadn't done a bedbath for probably most of that time. I did a lot of night float, etc. Anyway, my first bedbath took me till 2:30 in the afternoon - my instructor was not impressed!

    Now I am going back to nursing after 11 years away. I write my refresher course exam in just over two weeks. And you know what? I am just as terrified now as I was all those years ago. I feel like I can't remember anything and I am scared peeless.

    When I first graduated as an RN, I felt like such a fake. I found that most of the real nursing I ended up learning on the job. And most other nurses were always comforting and happy to show you anything you are unsure of. So don't worry = hang in there!

    Linda at Sundance

    P.S. You know you have really done a clean-up job when you have to clean up the feces an older patient has been finger-painting with and clean it out of his teeth - when they are NOT false teeth!!!
  12. by   canoehead
    OK Kirsti I give up... where DID the corn come from???
  13. by   crnasomeday
    You'll get faster at cleaning patients up Zach. It is really time consuming at first, but then with practice you just learn to get it done much faster. And don't feel bad about your assessment skills either. Those skills get better with practice as well. I think every nursing student at the beginning of clinicals feels like they just don't know anything. It gets better, and pretty soon you start to really amaze yourself. As far as pericare goes, I always clean from both sides. I mean I figure, why not. You end up having to roll them each way anyway to change the bed sheets and pads.

    BTW.... a bruit sounds like a "swoosh" kind of noise, and is distinctive enough that you would know it if you heard it. You can get a good idea of what one sounds like if you place your stethoscope over a dialysis patient's shunt.
  14. by   zacarias
    Hey guys/gals!!


    THANKS SO MUCH for the great and encouraging posts. They really help, y'all have no idea. Last week was especially hard and it was great to hear (see) you're uplifting words.
    The second day of scary patient (my nickname for this man LOL who basically is catatonic looking) I tried to find pedal pulses. Could not find his dorsalis no matter how hard I tried. What made it worse was that my teacher said he had good pedal pulses. I mean I can find them on other people, but not him. Then also my instructor comes in and says, "Why is he red like that?" I wanted to say, "Maybe cuz he should have been at breakfast an hour ago but you kept me from getting him dressed as you wanted to watch me do a cardiac assessment on him but you kept doing other things and wanted to come back to him" but I refrained.
    Kristi, your corn story is hilarious and I can tell you have a GREAT sense of humor!! I thank you so much for your head-to-toe assessment letter. I printed it out and will refer to it a lot. It's great and it is totally apparent that you have a great grasp on critical thinking in the clinical setting. I hope you're proud of yourself.
    Anyway, thanks again for all the help I received from you guys. Never think your words go unappreciated.

    Zach

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