First Day Back In Clinicals

[shoegalRN, RN]

Hello,

I am a 3rd year BSN student in my 3 of 5 semesters. Today, was my first day back in clinicals in my role as a Student Nurse. I have been working as a Nurse Intern II in a hospital that is in the same network as the clinicals I am doing. My clinicals are on a stepdown telemetry floor and luck shall have it, I work on a Med/Tele floor, so I'm familiar with the monitors and such.

However, when I'm at work, I do more techinical stuff, such as Q4 VS, Blood sugars, beds and baths, D/C and inserting foleys, JP drains, dressing changes, D/C IV's, etc. Basically, I do the work of a CNA, as well as limited nursing duties under the watch of the nurse.

My problem is in clinicals, I struggled trying to get back into the role of nursing student. I completely forgotten how to do an assessment. I mean, I didnt forget, but I wasnt as through as I would have liked to been. My patient had a chest tube on the left side and I couldnt tell the difference between crackles or wheezing, I couldnt hear the respirations that well on that side anyway because they were diminished.

I talked to my clinical instructor about it and she suggested that when I'm at work to practice doing assessments on the patients and then compare my findings to what the nurse noted and see if I can tell the difference between any normal or abnormal findings. I would love to do that, but the problem is, as a Nurse Intern II, I don't think that's within my scope of practice, even if it's just for practice. My clinical instuctor said she didnt think some nurses would mind.

So, my question is to all the nurses, would you mind if a student did an assessment on your patients for practice (after they've done their job duties of course)? How would you feel about it? Do you think I would be overstepping my boundaries if I done one while I done my Q 4 VS? (if it's time?)

All responses are welcomed!

[Riseupandnurse]

I would not recommend you do that, unless it's part of your nurse extern opportunities. You have no assurance that the nurse ahead of you assessed correctly, or that things haven't changed for the patient since the nurse assessed. I know several nurses who would not appreciate your assessing their patients, and I'm not sure all the patients would welcome it either. And then what if you heard something very abnormal that the nurse did not note? Surely you would feel obligated to bring it to the attention of the nurse. That may very well make some nurses think you are checking up on them, and they will resent it. In addition, all it will take is just one instance when a patient needed VS taken or an accucheck and you were busy assessing, for trouble to ensue. Does your nursing school not have a simulation lab, with mannequins with breath and heart sounds? That would be a much better choice, IMHO.

[NewEastCoastRN]

I have to say I disagree with the poster above. I think practicing while working as a nurse assistant is a great way to learn assessment skills. And think of all of the great opportunities you have to fit assessments into your daily routine - during a bath you can listen to lung sounds and check for skin integrity, during vital signs you can listen to heart sounds, etc. In fact, this is one of the best ways to learn the time management skills you will need as a nurse!

And if you encounter new findings with the patient's condition and bring it to the attention of the nurse, that is great! I would not be offended at all if one of the students brought it to my attention. After all, the patient is my #1 priority, not my pride.

[Megsd, BSN, RN]

Since you don't want to risk going outside your job descrption/scope of practice, I think a better option would be to utilize your patient's nurse in clinicals. Do your assessment, find the nurse and say "Would you mind listening to X's lungs? I listened, but I can't quite decide what it is I'm hearing, so I would like your perspective." In theory, the nurse is doing and charting his/her own assessment of that patient anyway, so it is a good (and more reliable) way to see if you were on the right track. Sometimes in school I got confused about crackles versus rhonchi, and I would ask my nurse to listen and tell me what they heard, and we would discuss any discrepancies.

[Katie82, RN]

You're doing this for practice and your own benefit. There is no documentation, no impact on the patient. I can't see where anyone would object, I wouldn't. If you have time.... It would give you an opportunity to compare your findings and perhaps ask the nurse how they arrived at their assessment. Just have to be sure that you do not appear to be second-guessing them. I guess it would depend on the nurse, whether she has time to spend with you if you have questions. Assessments are non-invasive, and it's something that CNAs should be doing already, within their own scope of knowledge, so why not?

[shoegalRN, RN]

I would not recommend you do that, unless it's part of your nurse extern opportunities. You have no assurance that the nurse ahead of you assessed correctly, or that things haven't changed for the patient since the nurse assessed. I know several nurses who would not appreciate your assessing their patients, and I'm not sure all the patients would welcome it either. And then what if you heard something very abnormal that the nurse did not note? Surely you would feel obligated to bring it to the attention of the nurse. That may very well make some nurses think you are checking up on them, and they will resent it. In addition, all it will take is just one instance when a patient needed VS taken or an accucheck and you were busy assessing, for trouble to ensue. Does your nursing school not have a simulation lab, with mannequins with breath and heart sounds? That would be a much better choice, IMHO.

No, my school don't have a simulation lab. If they did, there would be no need for this post. It would nice if they did. However, they do have mannequins with pulses and heart beats, but nothing like a breathing mannequin.

And I would not assess a pt until AFTER I've done my job and IF there's time. Not trying to take over the nurses job and not doing what I am being paid to do. I'm not trying to "play nurse" while I should be doing my TECHICNAL duties. If there is time, and after I've ASKED the nurse for permission to do so, THEN and only THEN I will listen to the heart and lungs of a patient (if it's ok with said pt of course).

My assessment will not be documented, it's just for my knowledge. And if I was to hear something abnormal, I would alert the nurse STAT, and that's no different as me alerting them when I get an abnormal BP or Blood sugar reading. Would you be offended if I DIDNT bring that to your attention?

Most of the nurses I work with know I am in nursing school and several have taken me under their wing and showed me alot of things and I am grateful for that. In a way, when I am taking VS, I'm doing an assessment by looking for edema or redness at the IV site and doing skin tugor and capillary refill. I'm just not listening to heart or lungs and that's where I need the most practice.

Anyway, thanks for your input.

[shoegalRN, RN]

Since you don't want to risk going outside your job descrption/scope of practice, I think a better option would be to utilize your patient's nurse in clinicals. Do your assessment, find the nurse and say "Would you mind listening to X's lungs? I listened, but I can't quite decide what it is I'm hearing, so I would like your perspective." In theory, the nurse is doing and charting his/her own assessment of that patient anyway, so it is a good (and more reliable) way to see if you were on the right track. Sometimes in school I got confused about crackles versus rhonchi, and I would ask my nurse to listen and tell me what they heard, and we would discuss any discrepancies.

While in clinicals, we also chart our own assessments. But I will do that in the future. Since it's our first day back, I will make sure to keep this in mind for next week.

[shoegalRN, RN]

I have to say I disagree with the poster above. I think practicing while working as a nurse assistant is a great way to learn assessment skills. And think of all of the great opportunities you have to fit assessments into your daily routine - during a bath you can listen to lung sounds and check for skin integrity, during vital signs you can listen to heart sounds, etc. In fact, this is one of the best ways to learn the time management skills you will need as a nurse!

And if you encounter new findings with the patient's condition and bring it to the attention of the nurse, that is great! I would not be offended at all if one of the students brought it to my attention. After all, the patient is my #1 priority, not my pride.

Aww, I would LOVE to work with you! LOL!

I would ask the nurses before hand if they would mind me doing it after I've done all my other duties. Most of the nurses I work with don't mind at all. In fact, I had the day nurses asking me to stay on days because they liked working with me so much. Then I went to nights for a couple of nights and the night nurses asked me to work nights.

I'm learning so much and getting my time management skills down. I'm also trying to get in a routine. I see it has helped me in clinicals, but not so much as doing the assessment.

[ukstudent]

You need to get apical pulses and respiratory rates anyway. While listening for the heart rate and counting, listen a bit longer and try and find the S1 S2 and murmurs. Listen to the respirations while counting them. You can do this and not step out of any boundaries.

[shoegalRN, RN]

You need to get apical pulses and respiratory rates anyway. While listening for the heart rate and counting, listen a bit longer and try and find the S1 S2 and murmurs. Listen to the respirations while counting them. You can do this and not step out of any boundaries.

I didnt think of it this way. I usually count respirations by looking at the pt inhaling and exhaling for a minute while getting their VS. Instead, I think I will tell them I'm going to count your respirations and listen to them breath and count them that way instead. That's a good idea!

All of my VS are done on a machine that gets BP, pulse rate, O2 saturation, and temp so this is the reason why I havent actually listened to heart or lung sounds.

[nursemiki1]

I have a question about toe stepping myself. I struggled at one point academically; now that I have additional resources, I'm learning quickly and efficiently. Today we entered our last quarter, one of three clinicals. I had studied ahead and was able to answer a lot of the clincial instructors questions. I do not want to appear as a know it all nor do I want to outshine anyone. However, I feel so good about being able to successfully assimilate the info and apply it, I feel so much like participating. We also have a lot of papers due this semester, most of us work full time and go to school on the weekend. As an adult student how is one expected to operate? I worked as an administrator for ll years; I am working in casemanagment right now to allow for flexibility. Any advise? thanks much.

[Kim O'Therapy, BSN, RN]

To the OP:

I have been a nurse assistant for seven years, so I can empathize with your situation. I'm in my Med/Surg clinicals now and I find it hard to switch gears to student nurse during clinical rotation. Instead of concentrating on "my" patient(s), I tend to run off and answer all the call bells by the third ring (this was a requirement where I worked). My instructor(s) constantly have to remind me to stay on task as a Student Nurse. As for assessing patients while you're at work.....I guess that would be up to the staff. I don't know how you would find time. The med/surg floor I worked on was so busy (I worked evenings) that by the time I could do practice assessments, the patients would be sleeping.

When I returned from holiday break, I had forgotten basic assessment skills; however, I could still crank out VS quickly. Good luck.