Can't get over clinical internship

[aw649]

Help! This is my third time in my clinical internship, which is the last hurdle for me to graduate. Academically, I am a 3.5 but the clinical internship is holding me down. I admit I get nervous and need more guidance on the critical aspects of prioritization. Clinical was much easier since we only had 1 patient. But in the internship, I get 4-8 patients to deal with instead of 1. I think I get overwhelmed with all the information I need to know for the patients and the time management I have to be in with each patient for assessment. I have been doing well with the medication passes and had become efficient at it. I still need to work on what to say during huddle and how to give report. Maybe I should ask my preceptor that I practice on 2 patients first instead of knowing all 4-8 patients, that way I won't get overwhelmed. Then gradually increase the number of patients as I become more comfortable with the process? Right now I am thinking that maybe I should have gone to pharmacy school because there is less psychosocial involvement and no giving report in retail pharmacy. Any suggestions on how to pass this hurdle?

[Rose_Queen, BSN, MSN, RN]

Since you mentioned report and huddle, do you utilize a brain sheet? If you use the search feature, you will find a lot of examples of the brain sheets used (I don't personally use one in my specialty, but some of the examples are pretty good). The best way to get past this hurdle is to practice, practice, practice. You could even take case study patients, complete a brain sheet on them, and practice giving yourself report.

[strawberryluv, BSN, RN]

Print out each patient's recent hospitalist note which summarizes their treatment. Also, get a brain sheet. Look up labs and nursing orders for your patients as soon as you get on the unit. Jot down the times for your med pass for each patient.

[aw649]

Thank you Rose_Queen for suggesting the brain sheet. I looked it up in google images since nobody even mentioned about a brain sheet. It's actually useful because it's sort of like a head to toe cheat sheet but with extra pertinent information. I shall practice giving report and eventually it'll calm my nerves.

[Here.I.Stand, BSN, RN]

Yes, use a brain sheet!! I don't have a formal pre-printed form that I fill out, but I make my own. I note my pt's name, age, admission date, and primary service (some of my colleagues just use a pt label). I also write down important things to remember such as BP parameters specific to that pt (keep SBP 65), family password for phone info, pt cannot turn onto Lt side, etc.

Below that, I make a note about their admission and important pieces of their hospital course. Something like John Doe, 25M 3/3/15 GSW to head (bullet not removed), Lt shoulder, Rt neck involving carotid and IJ (IR for embolization ---> stroke)

If it is a multiple trauma, I list their injuries and what surgeries they've had so far; if it's a particularly long list, I'll group them by neuro, ortho, internal injuries etc.

Then I make a space for assessment data by system head-to-toe: Neuro, HEENT, respiratory, CV, GI/GU/Renal, Skin

I make a space for drips, a space for lines, one for labs (important ones from last shift, AND ones that I have to collect), one for meds (I write times of scheduled meds in red; also note available PRNs if it's someone who needs their PRNs on a pretty regular basis), and one for miscellaneous notes (e.g. going to LTACH tomorrow, care conference tomorrow, etc.)

One thing that I started doing in school and still do, is to write my tasks in red. Scheduled med and lab times, times to increase the tubefeeds, lines that need pulling, tests I have to accompany the pt to, dressing changes that need to be done, etc. I missed some meds in clinical, so I started doing this as a visual reminder.

Now unrelated to the brain sheet, how you're suggesting working up to a full pt load is exactly how I did my internship. My first day I shadowed w/ my preceptor, 2nd day I took two pts, then I took 3 for a few days, and then the full load which was 4-5 pts.

[Nonyvole, BSN, RN]

Brain sheet, as others have said.

For reports, also look up SBAR. Perfect way to organize your thinking when talking to somebody else about a patient.

Situation: "This is Mr. John Doe, 45. He was admitted with a diagnosis of X three days ago after having a witnessed syncopal episode at home. He's being seen by Dr. Awesome, as well as the medical students and residents."

Background: "He is allergic to PCN, sulfas, and iodine. He has a past medical of CHF, HTN, NIDDM. Past surgical of appy... He's currently on a whole list of meds which are up to date in the MAR and the next batch are due at 0800. We're still waiting on morning lab results, but his 0600 POC glucose was 120. Yesterday's labs were all within normal limits."

Assessment: (keep it simple!) "He has a 20-gauge in his right forearm which was placed yesterday. NS with 20 K going at 75ml/hour. He's up ad lib and knows that he needs to use a hat in the toilet for Is and Os. Cardiac diet. He's on tele with vitals q6. Cardiac rhythm is sinus rhythm; he's showing the odd PVC but Dr. Awesome knows about that and isn't concerned at this point in time. Oxygen at 2 liters when he sleeps; there is a nasal cannula already hooked up and he knows how to turn on the oxygen. Lung sounds are clear bilaterally..." this is where you go through a review of systems.

Recommendation/requests: "He's scheduled for PT eval today at 1000. Dr. Awesome has asked to be notified of any critical lab values on his cell phone, but he said that he'd be here at about 0900." What is the plan for this patient? Anything that you didn't discuss already? Oncoming nurse have any questions?

And so on. Can't say much about using brain sheets - I'm in the ER, the closest thing that I get is a post-it note on my computer telling me that "Room 4 (pt initials) - CT @ 1800."

Good luck. Totally get you on feeling like you've been tossed in the deep end, but you've got a good plan of attack and you'll get through this.