How Should I Respond to a Bad Clinical Eval?

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by lcb lcb Member Student

Has 1 years experience.

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Hannahbanana, BSN, MSN

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB. Has 52 years experience. 1,187 Posts

I know this particular event’s time has passed, but perhaps, “How should we assess capillary perfusion and oxygenation in people of color?” would have been an opportunity for this instructor to talk about looking at nail beds, palmar lines, conjunctiva, oral mucosa … . Of course, it’s possible that she doesn’t know that either. It is also possible that this is another expression of the thesis of a book I ran into by accident in the stacks (remember actual, like, libraries?) when I was a student.

”Ritualistic Practices in Nursing” looked at the ways nurses assess and document. You can still get it, and its sequel, online. I learned that when I worked at my nursing assistant job on one ward, everybody had a respiratory rate of 20, that was shorthand for “No time to really count, but not short of breath or labored, and not too sedated.” I got floated to another floor once and they came down on me hard for charting “20,” because the convention there was “18.” Who knew? [[Also reminded me of the famous experiment with monkeys and cold water— I’ll describe that later— and the creepy Twilight Zone episode where the protagonist notes that all the onlookers to a fatality were breathing in unison, then that’s they were all dead too, and finally, the corpse in the street was his own. But I digress.]]

As I progressed in school, I started actually counting resps, and noted that not only did everybody breathe at different rates (d’oh, right?) but a lot of perfectly normal people have resting resp rates of 10-12 without pathology. (When I settle and focus on breathing to meditate, my resp rate is 4-5, and I am not hypoxic or hypercarbic.) This, when charted, engendered panic, because those numbers were the convention for “overdose of opioids.”

So what I think you ran into was somebody who used the language “pink and warm” not necessarily literally, but as a cultural norm to say, “Looks good to me.” Might even be true and accurate, but it doesn’t do a service to a new student who doesn’t know those “rules.” Nowadays I might look at that charting in a legal matter and say, “Hey, this guy isn’t / wasn’t pink, so this wasn’t really assessed.”  My retaining attorney would be verrry interested in that.

Might I suggest using, “warm and well-perfused with capillary refill < 3 seconds in nail beds all extremities.” You’ll be doing a better assessment and documenting something actually useful to boot. 

lcb

lcb

Has 1 years experience. 23 Posts

On 7/30/2021 at 8:16 AM, Hannahbanana said:

So what I think you ran into was somebody who used the language “pink and warm” not necessarily literally, but as a cultural norm to say, “Looks good to me.” Might even be true and accurate, but it doesn’t do a service to a new student who doesn’t know those “rules.” Nowadays I might look at that charting in a legal matter and say, “Hey, this guy isn’t / wasn’t pink, so this wasn’t really assessed.”  My retaining attorney would be verrry interested in that.

Might I suggest using, “warm and well-perfused with capillary refill < 3 seconds in nail beds all extremities.” You’ll be doing a better assessment and documenting something actually useful to boot. 

this is a GREAT point and exactly what I was trying to point out in the discussion. I was definitely not rude in the discussion with this instructor, at least not by my standards of politeness — I literally didn’t say ANYTHING other than to ask whether “pink” is really an appropriate term to use to describe all skin, and when she insisted it was I shut up and said nothing more — but my firm belief is that the ritualistic use of the word “pink” to describe all skin tones is in fact racist. It’s white-centering, because it implies that pink skin is normal skin and other colors are not normal. Using “pink” ritualistically (that’s a great word you use, love that way of describing it) to describe all skin tones is upholding racism in healthcare. It’s also inappropriate for the reasons you mention — it’s not an accurate assessment. 
 

Solidarity fist bump on the respiration counting. I am pretty good about *actually* counting respirations (I work in the ER so vitals could literally be anything at any time, we have no clue what’s going on with people when they come in so you gotta really look at everything), but I sometimes round up or down to chart a number between 12-20 when the person is conscious & talking & their breathing isn’t labored & their pulse ox is 100% but the respirations number is not quite within the standard limits. I’ve been thinking I’m just not very good at counting respirations, and I don’t want to flag someone and cause a panic when I’m confident their breathing is doing what it’s supposed to do, but maybe it’s just that normal is a much wider range than textbooks say!