Feeling green about 1st clinical site

MRed94 · Oct 11, 2001

Julie:

1. Breathe in.

2. Breathe out.

3. Do NOT forget # 1,2.

Hey! You'll be ok.

It IS scary, the first time you go there, but each time gets a little easier.

First things first....the instructor WOULD NOT let you go there if she didn't think you were prepared enough.....

Secondly, it is OK to admit that you are scared. ALL of us are, at one time or another...

I am scared, too, and I have been a nurse for a long time. But, being a student again, it frightens me.

You can always go with the truth....TELL the patient that you are new, scared, and just needed to tell them that. I think that once you do that, you will realize that you aren't really that scared.

Review your notes on assessment, and you will be fine.

Remember that the patient is HUMAN, and that he/she KNOWS that you are a student....

Treat them like anybody else, and things will go well.

REMEMBER:

Breathe in, breathe out.....!

:)

Marla

NICU_Nurse, BSN, RN · Oct 11, 2001

I hate to say this, but it's so neat to be out of that first semester and have those jitters gone (only to be replaced by NEW jitters, but you can't win, can you?)!! :>) Here's what I do, not just then, but now when I go to clinicals. First of all, take lots of deep breaths and picture stress and anxiety and fear as 'red steam' and calmness and wisdom and strength as 'blue steam'. Breathe out red, breathe in blue. I have been known to secure myself in the corner of the supply room to do some creative visualization in a pinch!!! Don't be embarrassed...you will be clear headed and focused, which will allow you to be the best nurse you can be. Secondly, realize that even the most experienced physicians and nurses started out just like you- scared to death not knowing what the hell they were doing. Lots of people just don't admit it- I'm one that does. I admit that I am a student. I have a limited amount of knowledge. I don't know everything. I hardly know anything. Tip of the iceburg, as far as nursing is concerned. What I do know is this: I am a great person. My heart is in the right place, and my mind will follow. If I am in doubt, I will hesitate and ask rather than risk harm to my patients, no matter how trivial or small it may seem. I forget things. I have used these IV pumps for two years now, and occasionally, I STILL forget how to program them. NO problem. I just ask. With a big smile and a wink. Humor helps. A LOT. So does charm. Lay it on thick. "I know I should probably know this, but you know us nursing students- totally worthless. *wink&smile* Would you mind showing me/reminding me/answering a question for me? I'd really appreciate it." "I feel comfortable asking you this, because you're so with-it and seem so knowledgeable..." Etc. Okay. Next step? When you go into a patient's room, or to their bed, remember ALWAYS that they are a person just like you. They are a son or daughter. They have a sister or brother or wife or kids. They may have a job, they may have experienced loss, they may be broke, they may have a heart of gold, they may be misled or confused...they're all people, just like we are. Exhale, smile, walk into the room, make eye contact. Connect with them. They are not a bunch of machines with a person thrown in there...they are a PERSON FIRST, with a bunch of machines and tubes to keep them company. ;>) Introduce yourself (again, even if you've met them before), ask them how they're feeling this morning. Any complaints? Did they get some sleep last night? I always make a little joke and smile my butt off to get them 'on my side', if you will. "So, did you manage to eek out an hour or two of sleep with all of these crazy people running in and out of your room all night?" I smile and laugh, maybe touch their arm if it's appropriate, all the while I'm connecting with this person. Pretend they're your favorite neighbor. Your best friend's dad. Whatever. Already, you're gathering important information here- if they don't respond, why not? Are they just lying there in a coma? Are they lying there with an irritated expression and purposely ignoring you? If so, what could be the reason for that? ARe they answering your questions and perhaps complaining about no sleep because of pain? Great! You just got pertinent info for your assessment. Patient is alert and oriented; c/o abdominal pain. Now, you want to be as specific as possible. (We always do an opening, head-to-toe narrative every morning.) They just said their stomach is hurting. Okay, how badly? Can they rate it? Can they describe it? Can they point to it? Take a look at the abdomen. Put on a pair of gloves, lift the gown, look at the abdomen. Wow, it looks okay to me...let's see... gently palpate (as appropriate- in some cases you won't do this, but you decide)...he moans as you barely touch his left upper quadrant. Okay, great! More pertinent info! Pt. c/o sharp, stabbing abd pain in LUQ rated 9 on a 1-10 scale. Tender upon light palpation. Or, you may see that their dressing is soaked through with blood...upon further inspection, you might find that their stiches have come apart and their abdomen is gaping open. Whatever- it will vary from patient to patient, but you get the idea. Chart it. I used to use looseleaf, then copy it over to the chart once it was approved by whoever (instructor, RN). The best thing to do is a head to toe. Start at the head. Go from top to bottom...look at the eyes...expression on their faces (smiling? Frowning? Facial drooping to one side?). Are they sweating? Anything unusual? Do the whole face. Great. Now move on to the neck...anything wrong there? Carotid pulses intact? Jugular vein distention? Nothing wrong? Look thoroughly, then move on down. Chest. Listen to the apical pulse. What does it sound like? Strong? Rhythmical? Skipping beats? Fast? Weak? Make a note of it. Listen to the breath sounds. Note them. While you're doing this, check out their skin. Scars? Wounds? Bruises? Anything wrong? Listen to the abdomen. Bowel sounds? Feel it. Tender? Soft and squishy? Does it look swollen? Is the skin tight and shiny? Check out the arms. Have them grip your fingers and pull with both arms at the same time. How is their grip strength? Weak? Nonexistant? Normal and strong? Can they lift their arms up? Move them around? Great. ROM is intact in upper extremities. Move to pubic area. Do they have a foley catheter? Is it unclamped? Draining? Kinked? Unkink it. Look at the collection chamber. Is there urine in it? Bloody urine? Clear yellow urine? Amber urine with clumps? Write it down. What about the pubic area? Is it clean? Blood present? Does the area around the foley look swollen or irritated or otherwhise abnormal? Note it. You get the idea. Simply move head to toe. Don't be afraid to use your flow sheet, if you have one. I have often used it to double check that I haven't forgotten anything. Don't worry if you have to go back and do something. I always say, "Alright, now, I appreciate you being patient becasue as you know, nursing students don't know a whit about nursing." winkwink. Of course, don't say this if you think they're going to freak out. Improvise, say what you think will be appropriate. I use a lot of Southern charm and thank them furiously for being patient with me, because when I started, I'm sure I took a reaaaaaaaaaaaaaally long time to do my assessments!!! :>) Do the head to toe. If you haven't done this by the time you're done, once you finish the head to toe, go back to the equipment. Does he have an IV? A heplock? Where is it? What does the site look like? Chart it. Hep-Lock to left anterior hand; dressing clean and dry, site shows no signs of erythema/infiltration/irritation. Is the heplock attached to tubing and an IV? Okay. follow the tubing up to the IV. Look at the bag, get the drug and dosage (10 grams, whatever). Then look at the pump, get the drip rate. Chart it. 0.9% NS IVF infusing at 120 cc/hr to left anterior hand. Is there more than one? Follow each tubing and chart it. One at a time. ONE AT A TIME!! Don't panic. Break it down into approachable bits. When you're done, ask if you can get anything for the patient. Ice? Water? Tell them when to expect breakfast, if they're allowed to eat. If not, tell them why they can't eat, and then tell them what you CAN do, ie, get them as much juice as they want, or get them as much ice and water, or only ice chips, or whatever. Let them in on the plan for the day. Okay, this is what I'm going to do...I am going to go write all of this good stuff down. I'll bring some apple juice and an extra blanket for you. We're going to get you out of bed for a bit and get you cleaned up, and you can brush your teeth like you asked me about before. While you're up, I'll change the sheets and all on your bed. After that, we'll see what else we can do for you this morning, okay? Then go do your thing. You get outside and you forgot something? No problem. Run back in and say, whoops, I forgot one thing...let me just check your eyes real quick...great, thanks Mr. Jones. I'll be back in just a bit and we'll get started. Big smile. Don't freak. ;>) YOu'll do great!!! I find that talking to them is really crucial...it puts us BOTH at ease. I talk to patients who don't even respond! I sing to patients in comas, I talk soothingly to patients who are disoriented, I talk to the walls if I have to!! ;>) I find that if they're alert and all, explaining what I'm doing helps also. Okay, now, I need you to flex your feet up like this for me...great...now what do you feel when you do that? Nothing? Any discomfort? Great. We do that because it helps us find out if you're developing any complications from being in bed so long...we want to keep you healthy so you get get out of here before the dawn of the next century!! You get the picture. You'll do wonderful. You will, I promise. You'll sweat, you'll freak, you may cry from panic, but you might not. Either way, you'll do a hell of a lot better than you think you will! Take stuff with you- lists of parameters, lists of drugs, calculation formulas, lists of vocabulary that you cant remember, whatever. Make a binder, and each semester, add charts and whatnot to it. It'll be your greatest resource. Copy coma scales and things on figuring caloric need and IBW and anything else you might need. A paper ruler to help figure out wound size. Things like that. Put a zipper pouch in there and throw things in that you can use. Paperclips, safety pins, a sharpie marker, small roll of tape, measuring tape, extra penlight, extra black and red pens, etc. Good luck, and email me if you need more help!!

A fellow student :>)

MRed94 · Oct 11, 2001

Kristi,

Ok, so you had just had 6 cups of coffee and were raring to go when you wrote that note, huh??? :):)

I copied and pasted it and will carry it in my wallet for the rest of my career.

I guess I never looked at head to toe in quite that way before..

What a wonderful job you did explaining all of that. I even feel better about assessing now...

Thanks!!

Marla

jschut, BSN, RN · Oct 11, 2001

Wow!

Somehow, I feel more calm than before! (Does that work?)

Thanks alot you guys!

Julie:)

MRed94 · Jan 31, 2002

bump

nehi · Feb 1, 2002

Kristi,

As a former clinical instructor I just thought I would share sometings with you. First, smile. You have chosen a wonderful career. Second,hold your head up. You had the guts to show up!

Third, instructors are scared too!!! I wish you all the best. If I can ever help just email me.

calililly · Feb 2, 2002

I was in the same situation when I started as you are now! I started my clinicals on the Sub-Acute unit-meaning the floor where 99% of the patients were on ventilators and almost all of them required total patient care and infection runs rampant. I was terrified: there were all of these tubes and machines going in and out of these patients and I was thrown into the situation with little more than my wits and a 'good luck!' from my instructor.

How did I deal? Well, it was actually easier than I thought: I kind of made it a point to get to know a couple of the nurses and pretty soon, they were letting me watch procedures that I wasn't allowed to do yet, calling me for med administration and telling me each patient's story: a young man who tried to hang himself but was found before he died, an advanced MS patient with respiratory failure, car accident victims, a drunk driver, pneumonia that was ignored until the respiratory system failed, childhood disease, etc. I began to find myself really getting into the care for these patients. I familiarized myself with their families, their clergy members (rabbis, priests, etc.), and the other staff members. Pretty soon, the nurses and RT's were showing me all about ventilators, decub's, G-tube feedings and med administration, trach care, and taking report from me as if I had worked there every day!

I won't lie to you-I accidentally disconnected an IV for about 5 minutes while giving a bed bath, and I kinked an oxygen tube attached to a ventilator without knowing-sent the alarms screaming! But I learned the floor, I learned my patients, and by the end of my month on Sub-Acute, I really felt like I had gained so much.

Sometimes starting out on a particularly difficult floor isn't so bad: you either sink or swim. You do what you've got to do in order to give the best care, and you end up doing it great after the first couple of tries!

I'm sure you'll do fantastic! I hope I didn't ramble too much!

calililly

mattcastens · Feb 2, 2002

You know, the best advice a patient ever gave me was during my nursing assistant clinicals (by the time I got into nursing school, I had a lot of experience with patient care as an NA). It was my very first clinical and I was being as gentle as I could -- walking on glass, as they say.

This old guy looks me in the eye and says, "Oh, for Pete's sake!! You won't break me!!"

It made me realize that perhaps I was thinking through things a little too much. I needed to relax and let the information I had learned work more on an instinctual level.

Now, I'm not saying that you don't need to think in your clinicals, because you do -- a lot. And I'm not saying that my way of learning will apply to everyone. But allow yourself to realize that you know what to do!

As was mentioned before, your instructor wouldn't let you do this if you weren't ready. The key isn't necessarily to know everything, but to know where to get the information.

zacarias, ASN, RN · Feb 2, 2002

Julie,

So this is your first clinical? It's interesting that they put you on a cancer ward first. Is it comfort care mostly?

Let me tell you, last quarter (first quarter) I was so scared of clinicals. I would be sitting through pre-conference hoping that she would say "no one has to do patient care today" because I was so freaked out! I felt I did bad at pericare, baths, etc...

After a few weeks people when asked would say that clinical was becoming "easier and more doable" to them. Well for me it was the opposite. It seemed every week I got a more difficult patient and I started all over with that scared, unsure feeling.

Ok, don't cry LOL cuz here's the good news. 2nd quarter clinicals for me started yesterday and I'm on a med/surg floor at a smaller (140 bed) facility. Both days I have felt stressed, anxious, excited, pumped, nervous, hyped ALL at the same time. There is no getting away that we'll be at least a little tentative/nervous for a little while at the start of each new rotation.

My point really, is that it will get better!! I doubted it myself that it would get better but it does. As you learn more things, meds, injections, IVs, patient teaching etc, you realize what you are doing is really leading to their recovery or comfort as the case may be.

Is your instructor on the lookout for interesting situations that you can help out in or watch? Ask her to keep an eye out for something. For instance, we don't give meds till next week but she is on the look out to find me people to give insulin shots. Today an IV infiltrated and she said, "Zach put on some gloves, you're gonna take the IV out." I mean it's exciting when you just gotta do what you gotta do.

Finally, ask questions! I ask SO many questions and frankly probably too many, especially when I start analyzing the patient's situation. I often try to look ahead from where I am in theory understanding. Do you have a clinical buddy (student)? Find a person you like/tolerate who has a patient near you and make a deal that you can ask each other any questions and help one another out at anytime.

Julie, I don't expect every day to be peachy, but I wanted to inform you of my newfound excitement that I'm experiencing now in clinicals, that I for one, thought could never happen a month ago.

jschut, BSN, RN · Feb 2, 2002

Zach~ (and everyone!)

I am much more comfortable with my clinicals now than before. I have learned the floor and the nurses. And I love it! I do a lot of patient care (and that's ok), Feb. 11 I will pass meds, and I take out INT's frequently. I feel good about myself now and more confident. I guess it shows!

I hope this thread has helped others who are feeling green about doing clinicals.

Believe me...it does get easier!

Thank you every one!

Julie:)

zacarias, ASN, RN · Feb 7, 2002

Originally posted by KristiWhite2377
Listen to the abdomen. Bowel sounds? Feel it. Tender? Soft and squishy? Does it look swollen? Is the skin tight and shiny?

Question: What does soft and squishy signify regarding the abdomen? And tight and shiny skin?

Z