Desperately need help with clinicals

sistasoul · Nov 22, 2007

Hi,

It sounds very stressful. I would arrive at clinical 15 minutes early and look through my assigned patients charts. I don't understand how your school works. We go the night before and get patient data from the charts and look up diagnoses and disease and labs, etc. I do know that when I am given a patient out of the blue I also have a hard time getting to look at their chart.

The only advice I can give is to arrive early. I think once us students get used to things we will have a little more time to look at patients charts. I know when I am in clinical it seems like the nurses get report and do their assessments. I hardly ever seen them looking in the charts except for meds and to see if Dr's orders had changed. I could be wrong though. I am still trying to figure it out myself.

Good luck

tlc2u · Nov 22, 2007

Thanks for the suggestion. I only wish it were that simple.

Actually I do get there early but I never know which nurse I will be assigned with until about 5 minutes before report starts. I have access to chart on my patients but I do not have access to print off the Kardex or the nursing worksheet that the nurses use. As soon as I receive my assignment for the day I then have to ask the secretary to print the forms for me so I have at least a little data on the patients. The nurses usually go ahead and begin listening to the taped report while I am still waiting on the secretary to print the worksheet or Kardex for me.

I like the Kardex best as it at least provides some info for the patient. However it depends on which secretary is there that day. Not all of them know which option to choose to print the Kardex. The secretary is usually very busy at that time of the morning also. One of them said she should just show me how to print them myself until she discovered when I logged in I do not have access to that screen.

I discussed this with my nurse last week and she said arrive earlier too until she realized that they don't give me an assignment until the nurses have their assignments and discuss which one has a caseload that is manageable for the nurse as well as the nurse training a student too.

APBT mom, LPN, RN · Nov 22, 2007

How many pts do you have. If it was me and going by what you put I would do this

Find which pt I have, find out their dx, get the meds, give them and do assessment at the same time, then fight for the dinamap (in my experience everyone goes for them first) if I know that the dinamap is screwed up I ask where the manual bp cuffs are and go straight for those because no one ever wants to do it the old fashioned way, then grab the chart/computer and start getting my info so by the time the CI starts to do her rounds it's directly in front of me so if she asks a question that I don't know I can flip for the answer real quick.

We also don't know who we are getting until we arrive to clinicals so I know how you feel about that. I wish we could at least get the dummy sheet that the nurses on the floor have because it provides the most current treatments that the patient is having. My biggest problem is getting the info I need because everyone comes and asks me questions, read what the MD wrote in the chart, or for help in my clinical group because I have the medical background.

Daytonite, BSN, RN · Nov 22, 2007

hello, tobrn, and welcome to allnurses! :welcome:

organizing my shift is something that has been a career-long pursuit. it never ends and always changes. as time goes on you get better at rolling with the punches.

the kardex isn't the only source of patient information. in fact, the chart is the original source of most of the information that is on the kardex! so, if you can't get access to your patient's kardex just go to their chart and start looking at the doctor's orders. the doctor's orders are where most of the kardex information comes from. some time ago i listed out the information that students should be gathering from their patient's charts as part of their assessment activity. it is listed on post #5 of this thread: https://allnurses.com/forums/f205/help-preparing-clinical-day-227507.html. the list of the patient's medications can be quickly obtained from the medication sheet. if you can't see today's medication sheet, look at yesterday's, or the most recent one, which should be in their chart and then look at the doctor's orders for the past day to catch up on any new meds were added.

i also wouldn't be waiting for a working dynamap. i'd get a manual blood pressure cuff and be doing vitals with a manual bp cuff and getting pulse and respirations. i'd invest my own few $$ to buy a digital thermometer and the cover sheaths for it at the drug store so i could take my own temps on patients. you can always confirm the temp with a dynamap later when you can get one, if you want. home health nurses use these digital thermometers all the time. you don't need a report from a preceptor to get vital signs done first. the fact is that in most hospitals, the nursing assistants are working on getting vital signs and answering patient call lights knowing nothing about the patients while the rns and lpns are in report. they don't learn anything specific about the patients until their nurses get out of report and give them more specific information or they ask the patients themselves. you don't get patients out of bed without knowing for sure that they are allowed. you don't give them anything to eat until you are sure they are not npo. it's that simple.

if you are able, open and print out the student clinical report sheet for one patient which is a link that appears at the end of all my posts. it will help you to write down some of the information you will need on a patient and organize your clinical day a little better.

vashtee, RN · Nov 22, 2007

What is a dynamap?

tlc2u · Nov 22, 2007

Thank You Sooo----Much for your suggestions. I love the suggestion of the digital thermometer. It would be so handy to always have one with me. Do you suppose the plastic sheaths to the home digital thermometers are as safe for not spreading germs as the sturdy plastic sheaths to the hospital thermometer. I may need to ask if this would be acceptable practice. I cannot afford to do anything that will cause my clinical instructor to have any concern. (We actually use a hospital digital thermometer now as the thermometer on the dynamap is consistently 1-2 degrees low. Our patients are immunocompromised and obtaining an accurate temp is important so we don't even bother with the thermometer on the dynamap.) On our floor each patient has a disposable blood pressure cuff in their room that you attach to the dynamap. We don't use one blood pressure cuff from patient to patient. Most rooms do not have a manual blood pressure cuff on the wall (as I have seen on other floors). Even if they do I am told that they need to be calibrated and they are not accurate.

Daytonite, BSN, RN · Nov 22, 2007

What is a dynamap?

Dynamap is the name of a company that makes an electronic device that takes digital blood pressures. It is also able to take and record the patient's temperature, pulse and pulse oximetry. They are expensive and cost several thousand dollars. In facilities that have them, these Dynamaps are used by the nurses and nursing assistants to take the vital signs of the patients.

tobrn. . .the plastic sheaths for the digital thermometers are only clean, not sterile, so it won't matter if you buy them from the drug store or use the ones the hospital has, if they even supply them. As for the disposable blood pressure cuffs, they should work with any manometer you use, just attach them to a manual one. All the cuff does is hold the air that you pump into it. Your manometer is what takes the actual reading. You are never throwing the manometer away.

tlc2u · Nov 23, 2007

All of you have been so helpful you have no idea how grateful I am to have a place to ask questions and receive knowledgeable answers and helpful input.

I am feeling still so overwhelmed at how little I know and how much I feel my clinical instructor expects me to know. And I do not understand where I am supposed to have gained this knowledge.

Things like who is responsible for ordering the appropriate diet for the patient or requesting a change in what appears to be an inappropriate diet choice. This patient has HTN as well as other cardiovascular concerns shouldn't this patient be on an AHA diet as opposed to the regular diet listed on the Kardex. Does anyone know who is responsible for changing this to AHA and the procedure taken to do so? I am sure the instructor would have a great time interrogating a student over this. My nurse never mentioned anything about this and I was definitely too overwhelmed with everything else to think to stop and focus on wether each patients diet matched their medical concerns. I'm sure one day all of this will become second nature to me when I am doing this everyday if I can only pass this clinical experience first.

I am currently trying to write a journal entry that addresses all the criteria listed on our weekly clinical evaluation record and yet carefully scrutinize anything that will cause the instructor to question things. I am afraid to include anything that is contradictory to a perfect ivory tower world. Example one patient is prescribed an antacid and another medication to be administered one hour apart. However when I looked up the interaction precautions these medications should only be given with one either 4 hours before or 8 hours after the other. When I questioned the nurse she exclaimed that in the real world it isn't always possible for everything to be perfect. I figure the doctor ordered this and the pharmacy filled this and the minimal concern that one med would cause the other to be slightly less effective is probably just that, a minimal concern. However it would thrill my instructor to watch me squirm as he grills me as to why we would have given these medications 1 hour apart (per doctors orders) instead of 4-8 hours apart (as suggested in the drug book). I do realize there can be serious consequences when medications are administered incorrectly so how are nursing students or new nurses expected to be knowledgeable of all the interactions, side effects, and dosage administration concerns of the multitude of meds they administer? How are we to determine to call the doctor or not when the concern of giving 2 meds closer together than suggested appears to be a minor concern?

I am just now getting used to where things are and becoming a little acclimated to the routine of the day. I am not adequately trained to just completely take over the care of 3-4 patients doing all the vitals signs, blood sugars, meal tray delivery and retreival, morning baths, changing beds, administering medications, new admits, discharge patients, look up all drugs for side effects and interactions, chase down equipment, provide wound care, troubleshoot IV's, d/c JP's, remove 48 surgical staples replacing with steri strips (just that task alone was quite time consuming), 3 seperate attempts to unsuccessfully place a foley, retreive a bladder scanner from another floor, scan the bladder, and return the scanner, etc. etc. etc.

However I feel this is what my instructor expects I should be capable of doing. This instructor has even the best of the students leaving our conference time extremely angry and frustrated with the endless drilling of arragant questioning. I never seem to be able to answer the questions satisfactorily and am in fear of failing clinically as the instructor has stated this could be a possibility if there is not improvement. My nurse feels I am at an appropriate skill level for a student and states she feels I would convey my clinical ability better to the instructor if the instructor had a more approachable attitude. This instructor has never been on the floor with me other than to drop in to interrogate me with questions about all my patients of the day and therefor I feel does not know anything of my clinical ability as well as this instructor has much higher expectations than what I am hearing of some of the other instructors.

Once again any advice is greatly appreciated.

Daytonite, BSN, RN · Nov 23, 2007

much of what you already know from living is going to help you through your nursing workday. right now, however, you are probably so anxious to do well and have so many other things on your mind that you don't see this. as you work in nursing and become more relaxed and confident with what you are doing you will begin to see how much of what we do is based in good old common sense.

significant changes in a patient's diet are made by the patient's doctor. the doctor is basically the "captain of the ship". have you heard that before? he writes all orders of treatment for the patient when the patient is admitted and this includes diet and activity orders. start looking at the admission orders (the first set of orders written by the doctor when a patient is admitted) of patients and you will see how extensive they can be. hospital nurses are really more restricted with what they can do with patients than you would think. the doctor must write an order for the diet and the nursing staff is responsible for making sure that it gets communicated to the dietary department. as nurses we can also consult with the registered dietician about diet concerns we have about our patient's. either we, the nurses, or a registered dietician can approach the doctor and request a diet change if we feel it is appropriate. still, it is up to the doctor to write the order. if the doctor doesn't feel it is necessary, then it won't get changed. each facility has a routine for how doctor's orders are transcribed from a patient's chart and carried out by the staff of hospital workers be they nurses or some other healthcare discipline.

how are we to determine to call the doctor or not when the concern of giving 2 meds closer together than suggested appears to be a minor concern?

well, outside of asking the doctor directly (some nurses are afraid to approach doctors for fear of getting yelled at), you can always call and talk to the pharmacist about this. the nice thing about working in a hospital is that there are a multitude of other healthcare professionals that we can collaborate and consult with. it is our right to do that. make use of a pharmacist's knowledge if you can't figure out where to find this information in a book. the pharmacists are supposed to know this information more so than we nurses. the pharmacists should have questioned an order such as this if they thought there was something funny about it long before any nurse gave the first dose.

i believe that some clinical instructors feel that it is their job to be harsh and act like drill sergeants rather than to be supportive and helpful. it is sad that they are like that. it sounds like perhaps your instructor expects you to find the answers to questions on your own. i can only suggest that you ask questions of the people around you. as i mentioned above, there are a wealth of people who work in the hospital who have a lot of knowledge from the unit secretaries to the licensed people such as the doctors and physical therapists. you can't be afraid to ask them questions such as "how do i go about getting a diet order changed?" a nurse or unit secretary can answer that question. all you can do is to keep on keeping on. it is never over until you are told to pick up your stuff and leave. never quit because you are told to quit--that is an intimidation tactic. in many cases they cannot kick you out of nursing school unless you do something that puts a patient in jeopardy or you flunk out.

one thing you can do is when you have a patient with a particular medical disease/condition is to find out as much about how it is treated by the doctor. this is part of what you are expected to learn as a nursing student since you will be carrying out or monitoring some of those treatments. in addition, you will be doing some nursing procedures aimed at some of the patient's symptoms of that particular medical disease/condition. now, you may not be able to get that information about the medical disease/condition right away, but as soon as you get home from your clinical day, it isn't over and you need to find this information. i set up a thread that has a whole bunch of links where you can find this kind of information. one of the best sites i know of to get this kind of information in concise listings is on the family practice notebook (http://www.fpnotebook.com/index.htm). if you have access to the internet when you are in clinicals it only takes a few minutes to get onto this website, input a medical disease into the search box and get a list of the information on a disease and it's treatment that will get you through your clinical day with your instructor. the thread these websites i've listed is at:

https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

just hang in there and keep asking questions.

tlc2u · Nov 23, 2007

You are a heaven sent blessing and so kind and prompt with answering my questions. When I become a nurse I'll owe a lot to you.

Yes I am very stressed with everything as the fear of failing clinicals looms very real. I am aware of 1-2 students failing clinicals for at least the last 4 semesters. One I knew personally though I was not in clinicals with this person however they were in my class and very genuinely a kind person to all. Unlike many of the students who never spoke to anyone outside of their little clicks, unless they had a curt remark to make. I still cannot understand the rationale as to why this student was told in the middle of the clinical day to collect their things and leave the unit. I personally would love to see a plan in place for nursing schools to have rules and guidelines that a student be worked with to remedy the concern and then if that didn't work they should at least have to call the student into the office at the school at the end of the clinical day to inform them of a clinical failure. To send a student packing in the middle of a clinical day and disrupt and stress to the max the other students as well is totally unprofessional and seems far removed from the care and compassion that I feel professional nurses should display. Oh, well that is a concern I'd like to tackle once I have been in nursing for a while.

Your suggestions are well received and appreciated. I worked with one nurse who carried a PDA and used it often throughout her day. For now I plan to borrow my sons device and check out and bookmark the websites you mentioned this way I will have access to info at my fingertips.

I know what you mean about life's experience being helpful to nursing but those are not the things my instructor grills me with questions about. I have no doubt I can care for patient's I have been doing it all my life. I raised 4 children all born with multiple birth defects requiring numerous visits and surgical procedures from a long list of different specialty medical fields. I am certified in medication administration and CPR in my job of the last 10 years and provide assistance to 5-6 MR/MH individuals who require all different levels of care from verbal assist to hand over hand assist to complete and total care with everything. Caregiving is nothing new to me. Being able to recall all the disease processes, pathophysiology, meds, labs, and pull together a multitude of bits of new information to get a thorough picture of my patient and their needs is what I struggle with. As well as how to priortize whose need is the most important and whom to see first. My instructor seems to be veiwing all of us nursing students as though we should be at the instructors level.

As I have said before often the questions rhat I cannot answer for my instructor, my nurses do not know the answer either when I ask them the same question. Now when they cannot answer the questions I will put your suggestion to work. Access the internet and look it up.

Thanks Once Agian

Daytonite, BSN, RN · Nov 23, 2007

I don't know what the deal is with the nursing school you are in, but let me assure you that most schools do not operate in the way you are describing. Most schools have a system in place where the student is taken aside privately and counseled privately. When a student is discharge from a nursing program the student knows exactly why. It is never done as a public display unless the student themselves want to make it into one. It works this same way on the job. I was a manager for some years and issues of job performance were never discussed with other employees. This, unfortunately, always opens the door to all kinds of gossip when a worker suddenly disappears from the work force. However, what goes on between a boss and an employee is supposed to be confidential; what goes on between an instructor and a student, especially if it involves their dismissal, should also be confidential.