GodIs082010 4,474 Views
Joined: Jul 1, '12;
Posts: 131 (15% Liked)
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It sounds like you have a really bad case of test anxiety when it comes to practical exams (many do). If possible, find something to help you relax prior to doing your next attempt (non-pharmaceutical). I remember flubbing up my last CPE with a bunch of self corrects that allowed me to pass (I don't see how self correction would be possible with a vital sign reading though) and drove home in my care literally wheezing from the stress. I knew it inside and out but the minute the instructor was there to check me off, brain blunder. I felt like a CVA patient with dysphasia. I new what I wanted to say be could find the darn words to spit out. Does you school offer free tutoring? Maybe practice with an instructor using the doubt stethoscope? The quality of those things are crud compared to some of the better quality stethoscopes out there so it's important to be able to hear it with the same type of equipment that you will be tested with during your exam. Also, practicing with an instructor my decrease your anxiety for the next time you do it for a grade.
You let yourself be upset for a little while (seriously. a very very small amount of time.) and then you shake it off and conquer it. Skills check offs are intimidating no matter how confident you are. They're rough but we all get through them. When you're testing, start with the easy stuff first, such as the brachial pulse, and go from there. You have to let yourself remain calm and focus on the task at hand. If you go in with the attitude of "I've already failed this, I'm gonna fail it again" then guess what will happen?
Confidence is key! You can do this!
Don't give up! Remember how hard you worked to get here. I felt the same anxiety regarding my blood pressure sign offs. I knew exactly how to do it, but I couldn't seem to get the clinical skill down. I couldn't find the brachial pulse, I couldn't hear anything etc. I kept practicing, I went to the school skills lab, and I used as many online resources I could. Eventually I got it and got my sign off. What is the specific problem you're having with vitals?
The nemonic for anticholinergic overdose or anticholinergic toxic psychosis goes like this:
mad as a hatter (delirium and hallucinations)
blind as a bat (fully dilated pupils and blurred vision)
red as a beet (hot red skin, fever)
dry as a desert
bowel and bladder lose their tone (retention)
the heart runs alone (tachycardia)
Caution: If you have a really good stethoscope, or even one that's really good for you that you wouldn't want to lose, make it theft-proof the day you take it out of the box. No, engraving won't necessarily do it. What you do is unscrew the little ring that holds the diaphragm in place, remove the diaphragm, and on the INSIDE surface of the diaphragm write your name in magic marker BACKWARDS, so that when you replace it your name is now perfectly legible.
This will not alter the acoustic capabilities one bit, but anybody else who has your stethoscope around his neck (yeah, the docs steal more steths than anybody) will have your name prominently displayed. Real deterrent. As a bonus, if you change your name later, you can't change engraving, but it's easy to put in a new diaphragm.
I use a classic II SE littmann stethoscope. This stethoscope, if you have the money (not too expensive compared to other littmanns like the cardiology III), as mentioned, will be great for nursing school and when you're an RN. You should shop around and find the best deal. I went to different websites looking for the same stethoscope, and finally found one that included the stethoscope plus engraving for less money than other websites offering just the stethoscope without engraving.
You should also practice using the cheap stethoscopes that you'll find in your school labs and in the clinical setting. When you demonstrate auscultating blood pressure, you may have to use a dual-stethoscope, which basically is two connected together so that the instructor can listen at the same time. You won't be able to use your own higher quality stethoscope, so you should also practice with it so you get used to listening with both. Also, in the clinical setting, you will encounter patients that are on some sort of contact precautions, preventing you from using your person scope. You'll have to use one of the cheap ones that the hospital has in the room. I just had to do that a few days ago at work (I work as a PCA part time), where the patient not only was on multi-drug resistant contact precautions, but had a condition where we couldn't use the automatic BP machine, and had to manually take BP. Got lots of practice auscultating and listening with the cheap scope that day!
I think that the OP is a pre-nursing student who needed to vent like any other college student......We have ALL had times when we were in school that we thought "Am I REALLY ever going to really use this crap?" Yet we graduated and passed boards...I think it is important to note that this is STUDENT FORUM where they come to vent frustration and voice opinions.
I think that we can ALL understand where the OP is coming from and empathize with his/her frustration at the moment....AND if we disagree we can do so politely!!!
Na+ and Water Balance, or why you have to remember that serum sodium doesn't tell you anything at all about sodium , and that saline is not water and salt.
OK, thought experiment time: Draw pictures with little molecules or such if you like, it will help. You have a beaker full of salt water, with a Na+ level of, say, 140 (hmmmm, what a coincidence). You pour half of it out. What is the Na+ level in the remainder? Right, 140, because that measurement is a measurement of CONCENTRATION, not a count of the absolute number of sodium molecules. Got that? If not, work on it, because you have to "get" it.
Now you refill the beaker to its previous level, full up, with plain water... or, say, D5W, which is the same thing, physiologically. Now what's your sodium level? Right, 70, because you have twice as much water per amt of sodium.
Go back to the half-full beaker again, the one with a serum (oooh, a Freudian slip! I think I'll leave it. Serum counts as saline.) sodium of 140. Fill it up with an equal volume of....normal saline, which for purposes of this discussion has a sodium level about the same as blood serum. What's the serum sodium now? Right, still 140. As a matter of fact, you can pour quite a bit of NS into a body and not really influence the serum sodium that much at all. The way you change the serum sodium is by changing the amt of WATER.
Repeat to yourself: "Serum sodium tells you about water balance." and "Saline is not sodium and water." (I used to have a poster of this and have my classes chant it three times before going on ....I wanted to be sure they would remember it for later)
OK, deep breath. Now we look at water balance from the other side.
Saline pretty much stays in its vascular place (unless you cut a blood vessel and spill some out). But water....ah, water travels. As a matter of fact, that's the other poster. Repeat three times: "Saline stays, water travels." (think: rivers flow from place to place, but the ocean pretty much stays where it is.) What the heck importance is that?
Back to your original beaker.... the one full of stuff with a serum Na+ of 140. Evaporate half of the water. What is the serum sodium now? Right, 280 (whooee, bigtime dehydration) As a matter of fact, if you lose enough water from your body to get your serum sodium up to 170 or so (("Serum sodium tells you about water balance")), you'll probably die, especially if you do it rapidly. Why? Because water travels in and out of all your cells. If you lose water from your intravascular space, sweat it out, or pee it out because your kidneys are unable to concentrate urine for some reason, thus making your bloodstream more concentrated, water molecules on the other side of the cell walls all over town say, "Whoops! Gotta go!"...because water travels across cell membranes from an area of more water per volume (lower salt concentration) to the area of less water per volume (higher salt concentration). So if you are de-hydrated, meaning water-poor, all your cells shrink. Most importantly, if your brain cells shrink enough from water loss, they pull away from your pia mater/meninges and you have an intracerebral bleed. Bummer.
(Interestingly, this is why you have a headache with your hangover after an alcohol binge. Alcohol temporarily disables your kidneys from retaining water well, so they let too much out. You pee a lot, and your brain shrinks just enough to put a little tension on your pia mater/meninges. Bingo, headache.) (Ahhh, digressed again....)
OK, now put this all together and tell me why your hematocrit is a lousy indicator of water balance (as a matter of fact, a nigh-on USELESS indicator of dehydration), but a good indication of saline balance.
OK. You are walking down the street with a perfectly good crit of 40 and a serum sodium of 140 (and normal other lytes). You are accosted by someone with a sharp thing and before you know it, a whole lot of your circulating volume is running into the storm drain. Fortunately, you are whisked into a nearby ER immediately, having had your bleeding stopped by a nearby Boy Scout with good First Aid Merit Badge training (ummmm, I teach that too). The ER nurse draws a baseline crit and lytes. What are they?
OK, crit is still 40...because hct is a *percentage of the blood that is red cells*, not a count of the absolute number of red cells you have. So even if you lose a lot of your blood, your crit is unchanged. Until they start fluid-resuscitating you with.... normal (not half-normal) saline (or RL, which acts like it for purposes of this discussion).
Na+ is still 140, because you have lost saline (serum counts as saline) but not water.
Thought experiment time again. Take two tubes of whole blood, that is, serum and red cells. They both have a Hct ( which is often spoken as “crit”) of 40, that is, 40% of the volume of each tube is taken up solely by RBC's. We already know what happens if you add saline to one of them: the crit drops, right? But what happens to the crit of a tube of blood if you add water-- like D5W? Answer: Nothing. Why? Because the crit is a % of volume....and when you add water, the water travels into the cells too. So they swell up, and their %age size change means no change in the crit of the tube. They still take up (in this example) 40% of the volume. What happens if, instead of adding water to your original tube of hct=40 blood, you evaporate half of the water out of it? (The answer is NOT, "Make gravy." Shame on you.) No, the hct stays the same, because the cells lose water too, and they shrink as much as the liquidy part did. Same percentage of red cells in the resulting volume = no change in hematocrit.
So. When you have someone dehyrated (as evidenced by their elevated serum Na+), you give him water (or D5W). This dilutes his serum Na+ back towards normal and allows his shrunken dehydrated cells to regain their girlish plumpness. Normal saline will not help, as it will not change the serum sodium level ("Saline is not sodium and water") and will not move into cells to restore their lost water content ("Saline stays, water travels.")
If you have someone who is hypovolemic, as evidenced by (hmmm? what? how do you assess hypovolemia? How about BP, CVP, JVD, PAd, LVEDP, etc? You pick 'em), you give him saline, which goes into his vascular space where you want it for circulating volume but doesn't go anywhere else. D5W will not do the job, as it will travel into cells (not just RBC's, but all cells, and most of it will thus not be available in the vascular space to make blood pressure).
So why do dehydrated old ladies have high crits AND high serum Na+'s? Well, as I was fond of telling my students, it's perfectly possible to have two things wrong at once.
Let's look at a couple of people and see if that helps.
1) Serum Na+ 140, Hct 25, BP 110/60. OK, so this guy is relatively anemic, but his circulating volume is OK (as evidenced by an adequate BP) and his water balance is fine (as evidenced by his normal Na+). Who does this? Well, anemia can have many causes, but if he comes in with a hx of a recent bleed with fluid resuscitation, you could guess that he had a perfectly good crit until he lost some red cells out his GI bleed or stab wound or bloody ortho surgery or something, and we were stingy and just gave him NS back. His crit is called "dilutional," as in, "His red cells are floating in saline."
2) Serum Na+ 118, Hct 40, BP 110/60. This guy has 'way too much water on board, as evidenced by his Na+ that's 'way low ("dilutional" too). We call him hyponatremic, but it's not that he has lost sodium (in most cases), it's that he retained too much water. He hasn't lost saline, as evidenced by his decent BP ("Saline is not sodium and water"). Who does this? Well, remember the dread "SIADH"? "Syndrome of inappropriate antidiuretic hormone"? Lessee.... inappropriate, ummm, too much. Antidiuretic, ummmm, doesn't allow diuresis, holds onto water.... Bingo. He's retaining water, and his Na+ is called "dilutional" because all those little Na+s are floating around in too much water. Some degree of SIAHD is actually pretty common--- you can do it with anesthesia, mechanical ventilation (there's stretch receptors in the lungs, see, and....oh, later), and a host of common meds. Of course, you can also get a low serum sodium in a hurry if some fool tanks you rapidly with a liter or two of D5W, or , like that poor woman in a SoCal radio contest, you drink a ton of plain water over a short period of time. She died of acute cerebral edema when her brain swelled up faster than her skull would stretch to accommodate it.
Hope this makes some level of sense. More?
Congrats on passing your first semester...!! i was just pinned dec 11th and graduated the 13th...it is a wonderful, wonderful feeling. Nursing school is truly the hardest thing i have ever done and honestly, i am glad i will never have to do it again. I completely agree with study groups! i am an older student but i didnt really have any trouble finding a study group...after a couple of weeks, you find out which of the students are a bit more successful and serious. for me, that was me and therefore, others wanted to join me. word of advice, limit your people to no more than 5, and make sure those five fit your groups style. yes, everyone learns differently, however, someone who's "style" completely clashes with your group, will not work best for the rest. In my group, there were 3 of us who were consistent for each semester and others came and went. Also, people will tell you A's are rare and C=RN. For me, A's were not rare, i got them in every single nursing course, however, not everyone did, but try your best because it IS doable! And while C does in fact equal RN, i have found that when applying for my first job, hospitals DO ask your GPA. So, if you are like me and do not currently work at a hospital as a PCT, being able to put an impressive GPA down is definitely a good thing. One week after submitting my application, I had one interview for PCU oncology and on Monday, i have another interview for GYN oncology at two different hospitals!
Care plans are not fun and are definitely time consuming, but put the time in. You will, in the end, save more time doing it well the first time instead of having to re-do them, as some of my classmates had to do. And to be perfectly honest, i would do 5 care plans to one mind map any day. i HATED mind maps....ugh. but, you will (probably) do them and get thru them.
I too, am of the camp that feels taking hand written notes works better. i brought my computer to class to follow the power points, but additional notes were hand written. i cannot tell you how many times in study group would my fellow "groupies" ask me a question about what the professor had said. i almost always had the answer written....
One final word of advice, (altho, maybe this part is for 2nd-4th semester)..unless your instructor tells you that you need to know a specific item, concept or disease process intimately, dont. stay in the shallow end of the pool. instead of having excessive in-depth knowledge or studying minute details (which will make you overwhelmed, burnt out and unable to remember as much), focus on a general understanding of the issue, and more attention on what you, as a nurse, can do for the patient and as someone else said, first thing to think about, safety and maslow....
also, if you are at a school that has ATI, find some time to practice it...not the first semester, but during your break before semester 2. having to find 5 hours to remediate on content from the last semester, while you are trying to learn new content is not fun. believe me, i know many people who had to do it...and if you're like me, you will be glad its not you.
good luck to those continuing and those just getting started.....you will feel AMAZING at your pinning!!!!!! and always tell yourself:
I CAN DO THIS!!!!!!
It can be very confusing at first, and I still have a little trouble with it. But some of the things to simplify for you.
Sympathetic nervous system HAS adrenergic receptors. Parasympathetic HAS cholinergic receptors. SO adrenergic and cholinergic are the equivalent of SNS and PNS. There are not adrenergic receptors in the PNS and no cholinergic receptors in the SNS. Also, both systems "run" at the same time. The activation of one, does not necessarily deactivate the other. Just during certain situations the receptors will receive more or less signal.
Also and adrenergic antagonist only blocks adrenergic receptors. It does not activate cholinergic receptors. And adrenergic agonists only increase adrenergic activity, they don't deactivate the cholinergic receptors. Same for cholinergic antagonist/agonist. Neurotransmitters will activate and deactivate each system when signaled to do so by various stimulations. If a tiger is chasing you, your adrenergic receptors will be sent signal to activate and start the fight or flight response. This will not deactivate your cholinergic receptors. It just wont excite them either. Then when you are getting ready to sleep, your cholinergic receptors will get sent the signal to activate, but your adrenergic system will not be shut down. It just wont get excited. If that makes sense.
Then, your drugs are used when you have a disease process that requires whichever receptors to be agonized or antagonized. This does not have affect on both systems. Just one. What I think is confusing you, is that when you antagonize the adrenergic response, it has similar affect to some of the effects of the cholinergic response. But it is not actually sending any signal to the cholinergic receptors. ONLY blocking the adrenergic receptor(s).
This will come with time. Up above, I just how I understand and have simplified the basics. You will find what works best for you.
I would suggest making two charts. One for SNS and one for PNS. Then add in your alpha and beta responses to the SNS and your muscarinic and nicotinic(if you are studying nicotinic) responses to the PNS chart. Then add in your medications and what receptor they affect. This will help keep things a little more organized for simpler learning.
Create your own support system. Like Commuter said, you, yourself are the best thing for you to rely on.
Secondly, create a support system. I had to create one when I was in school, because my husband left me and our 3 kids. My family sided with him. I made friends with other students, we networked in order to help eachother and we still do, as working nurses.
I had certain friends (not nurses) who I knew who were there for me, and I called on these supportive people when I needed to talk.
So I have been having some suicidal thoughts with clinical.
No need to be nasty. Everyone deals with things differently, and can have good outcomes too. Not everyone needs to be as assertive as you apparently are.
I didn't mean to start an argument with my topic, but I understand where everyone is coming from on this issue. While I agree that a doctor has no right to treat me poorly simply because he has a hard job, or because I woke him up (for a good reason),
hanging up on the doctor would put me in a bad situation. I'm sure my director would have words with me if I did that,
My preceptor is always there when I make phone calls, and I'm nothing but professional and courteous (and especially apologetic if it's really late).
Rude people are something that can't really be changed,
Most of the problem doctors aren't employed by the hospital, but simply have admitting privileges, which is why they don't really have a boss I could go to if they were being a jerk.
A) They are just voices on the phone and cannot hurt you (think 'thunder')
B) They work for the patient, not the other way 'round.
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