Gave my first heparin shot wrong, had a horrible clinicle day!!

[CrystalClear75, BSN, RN]

Hi,

I'm in my 3rd semester and since I never administered a shot, I asked my instructor if she could demonstrate it to me ONCE before I do it so I could actually SEE it in real life as opposed to a piece of sponge that we practiced on in skill lab, lol. I actually CALLED her personally at her home cause she was nice enough to give her phone number to all of the students in case we had any questions. So I called her and said, "Mrs. So and so, I never gave a shot and could you please show it too me one time so I could see it since I've never seen anyone give a sub q in the abdomen?" She said Yes. Well, when it came time at clinical yesterday, she told me that I had to do it. I was told by a student(an A student) that you give sub q's at a 45 degree angle. So, I piched my patient's skin and darted it in her abdomen 5 inches away from the umbilicus at a 45 degree angle. Btw, I was so nervous.:stone Aftewards, I was so happy and thought that I did it right until the instructor and I left the room and she said, "Where in the heck did you learn how to do sub q's? Do you mean to tell me you got passed of in skills lab on injections? You didn't hardly pinch the skin and you weren't even near a 90 degree angle?" I was so heartbroken and I told her I thought it was a 45 degree angle and she wrote me up and now I have to get remediatied. Which is fine with me, but she is supposed to be a TEACHER and I asked her nicely to show me and she let me down. Then, one of my meds was a nicotine patch and I forgot to administer it and left it one the patient's table and the instructor said "Did you administer the nicotine patch?" I said ooops, and hurried up in the room and it was gone! I think the patient stole it cause she was SO concerned about having nicotine patches cause she said, "Could you ask the doctor if he's going to prescribe these patches for me when I get discharged." I was thinking, yah, patches are expensive cause I use them myself to quit smoking. I know I was wrong about that too but I was so nervous cause in the midst of all this, I was doing Iv pushes and we never got passed off on that yet and my teacher said, "Well, you should know this by now so your doing it." I was so overwhelmed during this time, and on top of that, nervous about giving my first injections. Anyway, I checked that room for that patch inside and out, through the garbage cans with gloves on a milllion times, even the patient was helping me! Someone HAD to have taken it!!! Then, my instructor and I were getting the meds ready out of the drawer for my other patent and the meds were sitting next to her on the table and she told me to check on something(my patient) and I left the meds in there with HER and when I came back she said, "You should never leave your meds sitting there unattendended!" I said, "Well, your here and if you weren't I would have never did that." And I wasn't even GETTING the meds out, she was. Well, the instructor said, "What am I gonna do with you, i have to write you an UNSAFE for that and because you lost that patch." BTW, 3 unsafes and your out of the program, luckily I never got one. So I'm pretty upset right now, I don't feel like I'm nursing material at the moment and I feel that I need more hands on practice since I don't feel that I'm being taught very well in the clinical setting and I don't know, I'm just confused. I know I was wrong about the meds but I feel so bad about it. I made it this far (3rd semester) and I'm thinking about taking a job in a hospital somewhere but I want to do more procedures to develp competence. What should I do?

[Lisa CCU RN, RN]

I'm sorry you has such a bad day.

My advice is to never ask anyone how to do anything--look it up yourself or ask clinical instructor.

You only give a SQ injection at a 45 degree angle if you can't pinch a lot of skin (less than an inch or so). If you can pinch like two inches, go in at a 90 degree angle.

Think about it, you are trying to get the injection into the fatty layer--not the muscle--not the skin. So, you pinch the skin to pull the fat up and inject it into there. If you are going into the muscle (IM) you spread the skin taut so you move some fatty tissue over and target the muscle--hence going in at a 90 degree angle.

For Intradermal, you want to go within the skin. Not on top and not below, but within it. Pretty much right between the epidermis and the dermis. So, you go in at a 5 to 10 degree angle.

Think about what you are trying to do with the shots and think about the anatomy of the skin and muscle.

You need a longer needle for an IM shot. Why? So you can reach the muscle which is further down than fat and skin. You need a somewhat shorter needle for SQ. Why? Because you only need to reach the subcutaneous layer and you pinch up the skin to ensure you don't go any further than that.

Then you need a very short needle for ID because you barely want to go into the skin.

Ok, so I told you all this information. Look it up yourself anyways because for all you know I could be completely wrong and then if you do what I say, you will be doing it wrong too.

What I told you is right, but how can you be positive? Look it up for yourself.:) :) :)

Also, get a copy of the Davis RN Notes to take into clinicals with you to remind you of skills.

If you get checked off on skills and then don't have a chance to practice, you tend to forget how to do it.

Good Luck.

[MMARN, BSN, RN]

I'm sorry you are feeling so low.

Never, EVER, go by what anyone else tells you. That is one of the top things you are taught in nursing school (and you, more than me, should know this. I'm a first semester)

Also, the SQ injections depends on the patient. Actually, all injections depend on the patients. I was taught that you pinch the skin about an inch if the patient is thin. If the pt has a little more cushion, then you pinch the skin two inches. You always inject it below the umbilicus and laterally.

As for the meds, in my clinical, if my instructor saw ANY meds unattended and she found out they were ours, then we would go home IMMEDIATELY! We would probably be graded fail for the day. That's a BIG no-no:nono: . That has to do with the safety of the patient as well as our responsibility. Who knows what would have happened to a pt if he/she took the meds and od'd? (I have learned that you have to have that "worst case scenario" mentality.)

Your instructor should have been a bit more supportive, but always try to practice with a pillow or something in your house in order for you to refine your skills. The more you practice, the better. God bless you and I hope you have better days than this, which you will.

Mave.

[nurse4theplanet, RN]

Sorry for your bad clinical experience. I felt this way during my first semester. How long have you been doing clinicals? To make it all the way through to the third semester in our program without ever giving a SC shot is unheard of, but I know every program is different.

The best thing for you to do is be more assertive. You knew you had to give a SC shot the night before you went because you called your instructor ahead of time so you should have looked up the angle, guage, and length to prepare yourself instead of relying on another student. Start looking for procedures to perform on other patients if necessary and take a deep breath after you make a mistake and regroup. Once you screw up once, it sort of has a snowball effect.

Never take a medication into a patients room and leave it there. If you don't administer it, then you take it with you. If that had been a blood pressure pill and someone else took it, it could have potentially deadly side effects and you would be liable. If you feel you are a bit scattered brained and get side tracked while you are in the room, make yourself a checklist to read before you leave: did I get the vitals? give all meds? check a dressing? measure output? check my IV rate? etc. etc. whatever you have to do. This will help you be more organized.

The instructor should not have reprimanded you for leaving the meds with HER. Just to remind you though, always make sure you do not leave meds unattended and next time just ask her..."do you want me to put those away or are you going to stay here with them until I return?" Then she can't fault you. But I would put them away anyway, just because she could have to help another student with an emergency and YOU are ultimately responsible for those medicines.

[MMARN, BSN, RN]

If you feel you are a bit scattered brained and get side tracked while you are in the room, make yourself a checklist to read before you leave: did I get the vitals? give all meds? check a dressing? measure output? check my IV rate? etc. etc. whatever you have to do. This will help you be more organized.

I am a complete scatterbrain. Thanks for the advice. I'm going to use this myself in the future.

[mitchsmom]

Sorry you had such a bad day and that your teacher isn't really being helpful.

I would start taking my skills book (we use Clinical Nursing Skills: Basic to Advanced by Smith & Duell which has just about everything in it, link here:

http://www.amazon.com/gp/product/0130493716/104-0700681-0871147?v=glance&n=283155) since she seems unwilling to review the info with you.

Good luck to you, it sounds like it was probably just a bad day & hopefully the rest will be better!

[suzy253, RN]

You knew you had to give a SC shot the night before you went because you called your instructor ahead of time so you should have looked up the angle, guage, and length to prepare yourself instead of relying on another student.

Great advice. I do this myself when I'm finding info on my patient(s); what meds, what's scheduled, etc. so I can look up anything I'm unfamiliar with the evening before.

[epiphany]

You've been given great advice from asoldierswife05. A checklist in your pocket would help keep you from falling apart.

I used to practice my sc's on myself or a friend with the smallest needle possible, or an insulin syringe, using normal saline.

[LeesieBug]

I agree with the advice here, best way to get the info you need is to look it up yourself....

However, shame on that instructor! Whenever we do a skill for the first time in clinical, the instructors ALWAYS ask us to verbally tell them how we are going to do the procedure. That way, any information that we have mixed up can be corrected BEFORE actually doing the procedure. Then, the instructors will walk us through the first one if we want them to, giving us verbal instruction through the whole thing.

I don't understand the rationale behind letting students have at a patient before assessing his or her knowledge of the procedure...not good for the patient OR you.

Since your instructor is apparently lacking in this department, in the future I would simply stop her for a minute before doing a new procedure, and walk through the steps of what you plan to do, asking if that is correct.

Sorry you had a bad day.

[Tweety, BSN, RN]

I agree with your instructor for making you do it that day. You have to take these opportunities as they come up. If you did it in lab, it's time for you to do it in real life.

However you insturctor did let you down. A good insturctor goes over the prodcedure with the student prior to going into the room, if the student indicated she wasn't sure how to do it, or it's their first time.

Hang in there and best of luck to you.

[CrystalClear75, BSN, RN]

Thanks for all of your guy's support, I appreciate it. To the one poster who recommended a book, I actually bought another one called "Nurses's Guide to Clinical Procedures by Smith Temple." The one you mentioned was like 60 bucks and the one I bought used was only 12 bucks and it seems to have everything in it. It's crazy that we did not have a book like these listed on our required book list.

About the mix up of giving shots, I DID go over it the night before but I was told by a very good student that you HAVE to give ALL sub q's at a 45 degree angle so you don't hit the vessels. But now that I know, and thought about it, it does make sense to do it at 90 degrees on heavier people.

And about carrying a list around, I actually do, I carry the reports that I write from the nurse in the am, the whole written out sheet from the admissions, and meds etc etc. But like I said, I went from one extreme to the next and I have to be more on my toes.

[firstyearstudent]

I try to stay on top of my procedures by reviewing them out of the textbook, but if I'm suprised in a clinical environment and unsure or confused I quickly and discreetly ask my instructor right before. This doesn't make you look like a genius (and s/he might scold "You should know that by now") but it's better than doing it wrong on the patient.

I usually take my best guess and pass it by him or her: "I haven't done this yet. I go in at a 45 degree angle, right?"