1. hey all!

    hi folks! it's been awhile since i've looked at this board; i have a lot of catching up to do! i hope everyone is fine. anyway i have some concerns,
    i myself am in second quarter but for the last few weeks in clinical, i've been just dreading it. i feel like i'm so behind (even though there's no reason necessarily i should feel that way). i feel sometimes like everyone gets it and i don't. my clinical instructor thinks i'm highly intelligent but in reality i know so little!
    like yesterday, i had an end stage copd patient. i had trouble assessing his respirations. heard inspiration but nothing on expiration. didn't get to listen to the back really but apparently there were crackles which i have yet to hear on a pt. of mine. my teacher came in and said how he was a classic case of copd with a barrel chest (he didn't look barrel chested;he was thin) and she said he was using his accessory muscles to breathe which i wasn't sure i could see. i mean i know he was having a hard time breathing! she listened to the back and said he had basal crackles and a shorter inspiration time than expiration. well, that was a lot more than i got out of my assessment! i just feel like i have no idea what i'm doing. this patient had family there too when i started and i felt like they were judging me the whole time. how can work on this kind of stuff? i mean what does accessory breathing look like ..i mean so next time when i see it, i can chart accessory muscles feeling confident.
    anyway, i am told "you can't know it all, it will come" but what if it doesn't? what if by some fluke i make it to the end of school and then have to go out to a job? no one in their right mind would hire me if they knew. i am so anxious at clinicals i get sick..i often have to take ativan but i notice not a lot of difference. what's happening?

  2. Visit zacarias profile page

    About zacarias

    Joined: Oct '01; Posts: 1,352; Likes: 83
    RN; from US
    Specialty: 14 year(s) of experience in tele, stepdown/PCU, med/surg


  3. by   Josefin
    Hey Zacarias... I totally understand how you feel. I bet that most of nursingstudents/med.students feels exactly the same from time to time! I went on my last med rotation before christmas, and had a discussion about this with my supervisor. I complained that I sometimes feel like a big bluff, that Im really not sure about anything... She told me that she felt exactly the same before she graduated, but that you will grow in your new role once you get your licence. Are you at a teaching hospital (university hospital)? Then you should know that (at least is like this in Sweden) your department pays the unit you are doing your rotation on, to cover all the needles, papers and other stuff that students uses more than the regular staff. This payment is also to cover the extra time your supervisor must take to show and explain stuff to you. You should not feel like you are a burden to them! One of the doctors said to me that " you should ask EVERYTHING you are unsure of, this is a TEACHING hospital". I know you have heard it before, but noone expects you to know everything when you are on rotation. You are on the rotation to LEARN. The patient and the family are aware that you are a student too and doesnt expect you to be perfect! My advise is to actually try to RELAX. Tell yourself daily: Im doing my best, and when there is something I dont understand or something which makes me unsecure, I will ASK. And despite what you think: It WILL come to you in time, when you graduate you will have time to read about the speciality you will start working with.
  4. by   peaceful2100
    Oh ZACH, I have been wondering about you lately. Zach, I had the same problem you currently have now. As a matter of fact I am sure many can relate. I truly thought I know nothing and that I am going through school and wasting my time because I am not going to know anything by the time I get out to the real world. I constantly hear those I know who recently graduate say they have learned more in their first year of nursing then they practically learned the whole time they was in school.

    I truly believe a instructor will not pass a student if they knew that student is not going to become a good, competent nurse one day. I truly hope not. I think if you are getting satisfactory and passing marks then you are going to be Ok. Sometimes as students we often second-guess ourselves, and we worry more than we should.

    Your clinical instructor thinks you are highly intelligent. You feel as everyone gets it and you don't. Think about how many of your other classmates feel the same way.

    I was shocked to find out in my class I was not the only one who felt they were not getting it but the instructor said they were just fine.

    This is just a suggestion but it sounds like to me you have anxiety problems. Have you thought about seeing a counselor at school. It has helped me a great deal.

    Zach, if you really want to do nursing and it sounds like to me you want to do this based off several posts I have read from you then stick it out a little longer. You will start to get better at this and you will not feel quite the way you do now.

    I know I use to worry all the time. I still worry but not as much as I did in the beginning. It takes time to build confidence up and to learn what you are doing. Many nurses will probably tell you that they had the same problem too but now it has become much easier for them.

    If you feel that this is seriously starting to affect your health then you may want to consider sitting out a semester and taking a break but if you feel you can do this then keep trying and keep the faith. I know what it is like and many others do as well.

    "Remember rome was not built over night"

    Neither do nursing skills and nursing assessment.
  5. by   StudentSandra
    Zach, try to remember passing the boards means one has the minium amount of knowldege needed to become a nurse. This is not meant put anyone down. Most of what we will learn will be after we are out of school. We all feel the same way, but how one deals with it is what is different. Heck half the time I can't hear anything & I have a $200 Littman Cardio II. But being older I have a different outlook on things, I keep plodding along, figureing I will "get it" sooner or later, other times it makes me crazy too. I hate to say cliche things like hang in there, but we do all feel this way at some point, and it will get better, really it will.
  6. by   wsiab
    No one expects you to come into clinicals knowing everything.....you are there to learn and your instructor is there as a resource for you.

    It sounds like you have a good instructor that clearly communicates their findings to you.

    My best advice would be to take advantage of this instructor (if you are worried about upsetting the patient or family, you can talk to the instructor outside of the room, but your pt and family know that you are a student and probably won't react as strongely to you asking questions as you would think, use your own judgement for that). Let your instructor know that you didn't pick up on some of the things in their assessment and ask if they could help point them out (things don't always look like what you expect reading from a book)......Not saying anything to your instructor about this while you have this patient to assess is a missed learning opportunity, and you won't recognize it next time, not having seen it this time.

    Also, difficulty hearing breath sounds on a COPDer with a barrel chest is not uncommon....they are harder to hear. Go over the assessment with the instructor, have them point out where they are hearing crackles, listen there, borrow your instructor's stethoscope to listen if you need to. Also always listen front, back and R side, you miss lobes if you don't.

    I most of my instructors that were great about explaining everything the found in clear terms and they were open to discussing and explaining findings, they would go back and show you, and they were good about handling the situation tactfully so as not to upset the pt of family. I learned a lot from them.

    You are learning, it is expected that you will have questions, go out and get them answered...as to the anxiety, yes can be nervewracking, we've all been through it and you are perfectly normal. Isn't it great to have somewhere to vent and find a sympathetic ear.
  7. by   lever5
    The lungs become less elastic, therefore not allowing air to move at the volumes it used to. copd er's will breath in and then let the air out slower. We even have named this pursed lip breathing, most of them do it naturally, but some people need to be taught. This allows the lungs to optimize gas exchange. Called "blowing off carbon dioxide", sort of the opisite of paper bag breathing. Soooo the lungs become less elastic, they can no longer deflate as well, the chest will take on a different shape, mostlly copd er's have a sternum that is more prominent on the top. The first three or four ribs where they meet at the sternum will form a hump. You would have difficulty hearing crackles in a copd er they do not move air well in their bases if the disease is advanced. Leads me to wonder if this patient had mild symptoms that are sometimes missed by doctor's, If he was diagnosed with perfusion tests. If a copd er had crackles that are audible, it would be chf or pneumonia or something worse. Oh, and when you have a copd-er that is end stage, expect anxiety as one diagnosis. Anyone taken care of a copd patient on a vent?
  8. by   Agnus
    Sit down and tell you instructor what you have told us. Now when you are faced with this again ask the instructor to walk you through the assessment. The patient knows you are a student so this should not be an issue. Aske her to point out the assessory use. Tell you don't know how to see change in chest shape like, a barrel chest, and ask how you can determin that this is or is not present.
    As she listens to breath sounds follow her with your sethescope. In other words, when she removes her scope from a spot put your's directly on that spot and do this with each place that she listens. Expain to the patient before you do this that you are going to do it and why.

    Immediately after discuss what you heard and observed. You won't get it all the first time, but this is a start. I did this through school following many nurses (staff and instructors) with my stethescope. It is a skill. Skills are learned only though practice. But you are right first you need to fully understand what you are looking for.

    With acessory muscles use watch the clavicular area. Do you see shoulders or clavical moving. do you see the skin over the clavical sucking down with each breathe, Do do you see shoulders rising and falling with each breath. Does it appear like he is working hard? If yes to any of these there is probably acessory muscles that are being used.

    Barrel chest had nothing to do with the weight of the person. Often these will be little skinny guys. It has to do with the front to back ratio of chest debth. the chest is deeper front to back than side to side, with a barrel chest. lever5 has given you a good explaination.
    You are very intelligent. That doesn't not mean you know everything or are expected to get it all the first time. Learning anything takes time. Skills must be practiced to be learned and to be miantained, once they are learned. You instructor knows this. Keep practicing and you will find that this becomes and area of expertise for you. I worked on areas where I was weak and thought I'd never do well. Now I find those are my strongest points.
    Last edit by Agnus on Mar 13, '02
  9. by   zacarias
    hey all!

    thank you all so much for the encouraging words. this is very late in getting back to you and i'm just now catching up on some of the posts on this board.
    i am now in 3rd quarter starting clinical this week in a trauma hospital. i'm nervous but excited too because this quarter is where things are kicked up a notch and i will start to get to do more interesting procedures.
    yes, it is so great to have this support group for us students who often go through rough times during this journey. i appreciate you very much. oh and tonya, don't worry, i'm not planning on sitting out a quarter. that would be the last thing i want to do. the group of students i am currently progressing with is the most cohesive, caring group i've ever been a part of. it's also the most special group the staff at my school has ever seen, according to them. we even made an instructor cry once (ask if you want the story! lol).
    i'll try to read this board more often now to keep up on all your guys' successes as they are important to me.

    take care all!!!!

  10. by   peaceful2100
    Zach, I was starting to wonder about you. I am glad to hear things are starting to look up and go better for you. It gets better and better if you are determined and hang in there. I PROMISE, it is getting better and better for me each and every day.