Nursing Student's breakdown moment

[CC918]

Hello everybody. I'm a second semester nursing student. I am currently having clinicals in the SNF unit. Today I had my breakdown moment....I gave a PRN pain med after the PT told me my patient was feeling pain. I told the RN. She instructed me to give a Darvocet. Now, on the patient's notes, it saids to give 1 Darvocet for pain scale 1-5, and 2 pills for pain scale 6-10. It crossed my mind to ask the patient what was their pain level. But the RN said "Just give her one, she doesn't need two" and I stupidly did that.

Then my instructor came to grill me. "So you gave the PRN med?" yes. "How much did you give?" One. "What was your patient's pain level?" *me standing there looking stupid* i don't know. "Did you do a pain assessment?" *feeling stupid-er* NO.

I just feel so stupid for doing that. We've been told...YOU are the one giving meds, YOU do the assessment. That was my breakdown moment when I felt so incompetent and questiong whether I'd make a great nurse, or even a good nurse.

Then, I couldn't get my patient to let me bathe her. She insisted she got a good one yesterday and wants one tomorrow. But not today. I told her I have to give her a bath. She just kept telling me to leave her alone and if I tried to touch her with the wipes, she'd try to move away. So I gave up.

As a student, we are expected to do the AM care, including bathing and brushing. But what do you do if your patients just refuse to even after I persisted? The instructor always says "You should've been more assertive" . What else could I do, suggestions anyone?

Thanks for listening to my complaints.

[november17, ASN, RN]

It's not a big deal. Your instructor was just reading off a preset selection of questions to try to make you think on your feet. She probably asks those same questions to every nursing student that passes a pain med. You didn't make a mistake, you just forgot something. And really, if the patient was still in pain after the 1 pill, you could have probably given a second. Even though the order maybe didn't specifically state it, it's generally okay to do. If it freaked you out, you could have called the physician and I can almost guarantee you could get them to change the order.

You really more or less did the right thing, even if you didn't assess the pain first.

This reminded me of something that happened when I was in clinicals; One of my fellow students gave digitalis to a patient without assessing the heartrate first. It turned out that the pt had a heartrate of 60...She was crying during the post-clinical conference. She thought she was going to get ejected from the program, that she'd be a terrible nurse, blablablabla. The patient was fine in the end. The nursing student? I work with her...we hired in together to the same unit in May, and she does great and holds her own on the floor.

Just take it as a learning lesson. You didn't hurt anyone. Don't beat yourself up over missing a pain assessment.

If the patient didn't want a bath, she didn't want a bath. Just document that she refused it and move on. It's not like the patient is probably that dirty. I mean, she had a bath yesterday, and what did she do all day but probably sit in bed. It's not like she was outside making mudpies. I have patients refuse stuff all the time, it's not that unusual. Your instructor knows that, she's just trying to make you into a better nurse. Just an alternative though, you might have tried giving her the washcloth and washbasin and asking her to clean herself, then given her 10 minutes of privacy.

[Hellllllo Nurse, BSN, RN]

In the real world, I find that the numbered pain scale just confuses most pts. When you ask them to rate their pain on a scale of 1-10, one being...blah blah blah, they mostly just stare blankly- Huh?

I say "Do you have pain?" If they say yes, I say "A little pain or a lot of pain?" I then medicate accordingly.

I hate it when instructors and other nurses try to make us feel that if we were better/more assertive/smarter/caring or whatever, we would always be able to get our pts to do what we want them to do.

By insisting that you should have been more "assertive" in convincing the pt to have a bath, the instructor turned the focus of care away from the pt's needs and towards her own needs/wants as an instructor.

So, instead of stimulating students to think "What can I do to meet this pts needs?" Instructors encourage "How can I get this pt to let me do what my instructor wants, so I won't look bad?" type of thoughts.

I do understand that you have to do things the school way, and not the real way in clinicals, though.

[CoffeeRTC, BSN, RN]

I'll bet you did assess for pain in a round about way. Ever assess a nonverbal or confused pt. They won't be able to tell you the number. We us the Wong-Baker scalehttp://www.mdanderson.org/pdf/pted_painscale_faces.pdf

You will not always be able to get you the number and sometimes the number said won't match the physical signs.

Rule #1 in LTC is you cannot force a pt A &O or demeted to do anything.

[NursingAgainstdaOdds]

Don't worry about either issue much. Becoming a nurse is an awkward, often embarrassing, humbling experience - and, as a student you're right in the cross-fire (as previously stated by other posters) of reality and textbook. This will come-up a lot more during your clinicals. All you can do is your best.

The next time your instructor tells you to be more assertive, tell them "Well, I'd like to start my new assertiveness now, and say I think I was respecting the patient's wishes and doing my best to balance their needs with mine."

You certainly can't respond in this way every time (lest you be tagged as a "troublemaker"), sometimes you just have to smile and nod and cow-tow to your instructor while internally rolling your eyes. BTDT. You're doing great, don't worry.

[rn/writer, RN]

It's not a big deal. Your instructor was just reading off a preset selection of questions to try to make you think on your feet. She probably asks those same questions to every nursing student that passes a pain med. You didn't make a mistake, you just forgot something. And really, if the patient was still in pain after the 1 pill, you could have probably given a second. Even though the order maybe didn't specifically state it, it's generally okay to do. If it freaked you out, you could have called the physician and I can almost guarantee you could get them to change the order.

I have to disagree a bit here. If policy and procedure dictate that you use a pain scale, then you use it unless there is a compelling reason not to (altered LOC, speech problems, etc.). Even then you find other ways to assess and document your patient's pain status. Omitting the pain scale may not be a life-threatening mistake, but it is a mistake nonetheless. JCAHO and other evaluators (Magnet folks, for instance) DO look at these items and expect to see them in your charting. So do nurse managers and other nurses who may end up doing a peer review for you. I'm guessing your instructor is trying to instill this good habit in you now.

As for giving a second med, again, look at your facility's P&P and the orders. Are there any parameters listed? If the pain scale is one of them, you really need to incorporate it into your assessment. If there are conditions for giving a second med, that also should be followed.

Don't beat yourself up over these things, but DO take them seriously for next time. This is for your protection as well as the patient's. If someone comes along and tries to say you overmedicated a patient, it would be handy to be able to say, "He told me he had a pain level of seven, and that is why I gave two Percocets instead of one."

As for the washing up, I agree with those who say you can't force a patient to do something (or let you do something for them) that is against their will. What you CAN do, though, is make a gentle inquiry about the reason they're refusing. Are they too tired? Do they want to do it later in the shift? Are they feeling hemmed in and powerless and this is one way of taking control? (Obviously, you have to be careful how you word that.) Sometimes, as others have stated, it's nothing more than habit. Daily baths were not the norm for many people over the age of about 65.

Once you have this information, you can adapt the situation so that it suits them better (washing with help, washing after lunch, using baby wash instead of harsher soap, etc.), or you can document the patient's reason for declining as your subjective data. Sometimes that's all you can do, but no one will be able to give you too hard a time if you made this much effort and it still didn't happen. This is evidence that you weren't just blowing off a responsibility.

Think of doing these things for yourself as well as for your patient. It's important that you be able to give a good accounting of your practice to yourself as well as to anyone else who asks or evaluates you and your charting. Get used to doing things "by the book" before looking for any loopholes or shortcuts. Some do exist, but you need a little experience under your belt to be able to know which ones are legit and which could cause problems.

I wish you the best.