LovingPeds

I have been out of bedside care for 1 - 2 years now. I recently stayed with a relative during their hospital stay. In the 24 hours we were there, only once did anyone actually do a physical assessment using a stethoscope on a patient with respiratory illness and a history of cardiac complications. This includes providers, nurses, and respiratory staff. Vital signs, a quick radial pulse check, and dependent edema were assessed on admission. Vital sign assessment continued with the tech as routinely scheduled. IV was checked once with bag change. Other than that, nothing. I always did a head to toe shift assessment and then a focused assessment on my rounds. I always auscultated heart and lung sounds on my rounds as well even if not admitted for a cardiac or respiratory problem. I always considered assessment a basic standard of care. I am concerned about this whole experience. How are you able to start the nursing process without assessment? What have your experiences been? What do you consider to be the standard of care? This occurred over multiple departments and included providers so it's not an individual thing but systemic within their facility. The nurse to patient ratio was pretty standard for the clinical area for the shifts we were there. I'm curious as to what others do elsewhere because I've never encountered this type of behavior before in my own professional career and the systemic nature of it within the facility makes me wonder if this is normal in other places.

Honestly, I would have a conversation with your current manager first. Transfers within hospitals are common. I would let your manager know that you appreciate the experience and support that is being provided to you now and that you are interested in the special care nursery at some point in the future when you have more experience. I would let the manager know that you are aware that you have to have at least 1 year of experience before applying to the position there, but you would like to ask for the opportunity to shadow a nurse in the department to see if that is an area that you would truly like to aspire to. This is just an honest conversation with your current manager. I say this because if you ask behind your managers back, there is a chance that your manager will find out about it. Your manager will have no idea what your plans are, when you may be planning to transfer out, or if you are looking at other areas throughout the hospital for a job you can transfer to in the next month or two. In my experience, that has always been more destructive to a professional relationship than honesty from the start. Good managers support the professional development of their nurses because it benefits the organization as a whole.

If you have spoken with your instructor and not gotten any more information to go on, then my suggestion for you in this case is to reach out to the hospital's education department. All hospitals have someone who is in charge of clinical placement for the schools and they are often within the education department. This person should be able to give you more information to contact your clinical preceptor. This would be less disruptive than calling multiple floors to look for the nurse.

Maternal-child instructor here. Several BONs recognized the difficulty in obtaining student placement due to Covid-19. Our BON, for instance, decided to accept a minimum of 10% of clinical hours being with patients and that all other hours could be virtual clinical or simulation. It was left up to instructors to decide how many hours were in clinical and how many were in simulation so long as the minimum hours were obtained. I decided to do all of my clinical hours for my class in the hospital setting rather than simulation. As an adjunct already working daily directly with patients, I was comfortable that the students and I could do so safely and was not as comfortable with planning simulation or virtual clinical set-up. The other instructors for the semester did more simulation and virtual clinical than patient hours. All of it was accepted by our BON and these students are now nurses. If your Dean has told you that you could be licensed anywhere, then most likely the Dean is familiar with the educational changes allowed by the states due to Covid-19. Also in the US, once you have passed NCLEX, you can apply to be licensed in another state. This is usually done through applying, verifying your active license, and meeting their continuing education requirements for licensure. I'm not familiar with other states wanting to see your undergraduate clinical record to transfer or expand your license to another state.

With my senior practicum I was given the name, the unit, and a contact number. I had to reach out and introduce myself and schedule hours for preceptorship. I think it was the same way years later when I agreed to precept students myself. I received a phone call on my cell phone from students introducing themselves. It was not surprising, because I knew I had agreed to take on a student. In graduate school, I was assigned a preceptor for my acute care hospital work through the hospital. I had to contact doctor's offices myself to ask if anyone was willing for my primary care education. Some schools give assistance with preceptorship. Other schools have students on their own. It really depends on the school and the precepting environment.

I transferred to an ADN program for nursing. I had all the pre-reqs done for a BSN program and then some. This school required that you had an ACT within the past 3 years. My ACT was 4 years old at the time. I went to the school and asked them what I needed to do. I was told that my ACT score was really good and I did not need to retake it. Because that was what I was told - I didn't retake it. I then received a letter saying that I was not admitted due to an older than allowed ACT. I went to the school and told them that I had come to their office and did not retake the ACT because I was told my score was good and that I did not need to. They sent me to the college office to take the other option which was some type of basic literacy test. I passed with 100% and took the results back to them. They looked at my record and told me that I was "over qualified" for their program based on my completed pre-reqs and that they would make an exception to the admission date to let me in for that year, but not to tell anyone that they had allowed this. I understood because that could easily be construed as unfair. Schools make mistakes. Some times in the sending of transcripts, in records, or in advice. All you can do is talk to the staff, be polite and respectful in your conversation, and see what happens.

I had a male colleague in nursing school who went through the same thing. He was married, a few years older than his roommate, and had small children at the time. He and his roommate became and I believe remain good friends. We didn't judge him for it. Nursing school is time consuming and tuition is expensive. The roommate appreciated the break on rent. He appreciated the place to stay. I don't know all of the details, but I know that his wife met the roommate several times. They had exchanged numbers in case of emergency. I don't know that they became good friends, but she did become comfortable with the roommate. The trick for them was attributed to two things: transparency and video chats. He was very open with his spouse when ever he and his roommate were studying alone or going out to get dinner alone. He never made it seem like he was hiding information. He also video chatted her twice every night he stayed over. Once when right before his kids went to bed to talk to them and then once before bed himself just to talk to her. If it was a late night like with clinical, he took the time to chat with her for a few minutes before she went to bed. I think his family stayed so involved that way that it was like he was home. Another thing that I think was very helpful was study groups. When ever possible they invited other people to study with them or to have dinner with them so it wasn't just the two of them all the time. It was just clearly a professional relationship based on circumstances.

I work with the pediatric population. I approach vaccinations based first on age and then on their body language/response to getting a vaccination. For instance, all young children (especially 6 - 7 and under) I automatically have someone help hold starting at about 6 months. I choose the hold based on patient age and comfort. Most children around 9 when we start giving the HPV vaccine will sit nicely on their own and allow you to give it. If they seem nervous, I'll ask their parent or someone in the room to hold their other hand. Very seldom do we have to hold children for vaccination at that age. You do have people regardless of age who are not going to cooperate with vaccination due to anxiety and fear. That's not always specific to age, but more related to personality and phobias. I've had 4 years old sit and take a vaccine without help, holding, or flinching and had to hold 14 year olds down like they're toddlers. But in most cases, giving a vaccine to a 14 year old is very similar to giving it to a 34 year old. Very few people even as adults like getting a shot. It just depends to what degree they display that nervousness or displeasure to others so it's almost always a case-by-case basis. As far as quantifying the pain level of shots, I can't say that I can tell much of a difference between most of them. The HPV vaccine I always save for last because almost everyone tells me that one hurts. The others are very dependent on the patient's pain tolerance in general. As far as making it easier, I don't draw it out with explanations, but give them choices where ever possible. I basically go "You have to get a shot today. Show me your muscles. Look at those muscles. You have great muscles. You've got this! Which arm do you want it in?" If they are 4 - 5 years old, I'll give them the option between arms or legs. I've noticed they'll usually pick the thigh. I'll ask them questions about school or talk to them through the administration about anything but the administration and then tell them good job when done. Even if they were awful, I'll tell them good job! In very young children, we just get the process over with and they immediately get a sucker. It would amaze you how quickly most kids stop crying when they see it. In infants again we make the process as quick as possible and then they are cuddled and comforted. After care is very basic. I inform parents that mild fussiness, mild fever, and not feeling so well is a normal part of the shot process and can last up to two days. Anything other than that, they need to let us know about. Older children, I tell they may feel a little sore, but then encourage them to stay hydrated, busy, and to try to go about normal activities. Distraction works wonders. If they've had multiple vaccines from a catch-up schedule, I'll usually prescribe some Tylenol or Motrin as needed but in general we don't use it for routine vaccinations unless the patient is very uncomfortable.

It sounds like you did a very thorough assessment. This possibly could be used as a learning experience in order to develop a policy plan for these types of emergencies. From a liability standpoint, if the unforeseen happened and this child did have difficulties, became unresponsive, or stopped breathing on the 3 minute ride to the ED or in the event of a traffic delay in time of arrival under those circumstances, then nursing staff could be held negligent for failing to notify or wait for 'appropriate medical transport'. Especially if the documentation mentions the word 'lethargic' after a child states "I have breathing problems". You have enough to qualify an emergency call for medical transportation. I have to attend several 'conferences' a year on limiting malpractice liability per my employer to meet requirements for malpractice insurance discounts. They present a lot of interesting cases. This just seems similar to one of the cases reviewed from an office setting where the nurse accompanied a 'sick but stable' child to the ED by private vehicle. There was an accident on the way to the hospital which wasn't far and the child suffered significant injuries in the accident. The nurse and her employer were then sued for malpractice after the family's attorney blamed the 'emergency' for the accident (and their erratic driving) and then claimed that the child's condition was too bad to have been driven by private car and that there was negligence in failing to provide 'safe and timely access to appropriate emergency medical assistance' when they failed to call EMS for transport. It ended in a settlement and the end result of the insurer's recommendation that if a child is 'sick' enough to require medical presence in transport then they really just need EMS transport. The moment you decide they're sick enough to need a nurse with them while being taken, you've already decided they need close medical monitoring. It would be best to just make the call and wait out their arrival in the nurse's office rather than risk the unknown in a vehicle on the road away from any supplies that may help you in case of emergency. Good job handling a tough situation! Glad the kiddo was okay.

You can't tell by grades alone. You have to look also at content, but grades reflect that knowledge of content. Say someone makes 98% on everything antepartum I give them on two exams and then on their intrapartum test using a new test bank they miss every single question that refers back to that same antepartum content they had a nearly perfect score on previously. What are the odds that they knew the questions versus actually knowing the content? You either know the content or you don't. You don't have that much of a difference between test questions on the same content if you know the content. They only other logical change is the change in test bank source for questions.

I know of an L&D nurse who never worked any area other than L&D, PP, and nursery. She was very successful in her FNP program and has been successful in primary care since. You will review a lot of information in your program along with multiple clinical situations in different areas. If you study and prepare, you'll be fine.

Don't kid yourself that your instructors aren't wise to what is happening. The problem is an instructor can't say or do anything without proof. We have to see the student cheat. We have to take the student's word that they came prepared on their own mental power unless there is suspicious activity during the test or we can prove they have had access to our tests. I've watched students make failing grades on two tests, high 90's almost perfect on the next three, then when I change to new questions fall back down to failing grades for the rest of the semester. We know. We just can't 'prove it'.

I can't speak for their actions or reactions. Take it as a learning experience. Every one here has had one. If it ever happens again, you can specifically mention that he didn't get the full dose and show your preceptor and the physician the CDC recommendations for partially administered doses.

I never use the deltoid in a child less than 3 years of age unless they're having to be caught up and have a great number they have to get. I have had to give up to six vaccines for kids who are very, very behind. This is usually children who are around two or older. We always try to use combination vaccines if we can so as to not give as many shots. With six shots, it's sometimes necessary to space them out into the deltoid. I would not do this as a matter of general practice in toddlers though. The vastus lateralis is a larger muscle and is much easier to control for vaccination in busy little bodies. We do allow parents to restrain. I usually allow parents to make the decision for how to hold the child. They can either hold the child in their lap or we can lay the child down on the exam table. I'm comfortable either way so I give the parent the choice. They know their child and what may be easiest/most secure for them better than I do. Either way, with the thigh the parent is responsible for holding their arms and hands. I control the legs. I do not start until I am satisfied that the parent is in complete control of those little hands and arms. If the parent is not in control, then a nurse will hold the patient. If the parent lets go on any of the vaccines, a nurse will hold the patient. You have to have good control of what ever area you are giving the vaccine to. If you're giving it in the deltoid, then you need to hold that arm with one hand and give the vaccine with the other in addition to the parent holding. Never rely only on a parent or anyone else to solely hold and control that area for you. When you give the vaccine, place your wrist firmly against the patient's muscle and hold it there. Then use a downward motion for the injection without moving your hand. That way if the child moves unexpectedly, you still have control of that syringe because your hand has been steadied. It's a similar technique to bracing with your hand while looking in ears. If this child received a partial dose, then he wasn't fully immunized. Any dose less than the full 0.5 mL is not valid and will need to be repeated. Honestly, all of this is on your preceptor. They should have stepped up to help. They should not have let his child leave the office without that full MMR/varicella dose or any of the others. If it gets put into his record as a full dose, this child will not receive these invalid vaccines again as he needs to. The ease comes with experience. Don't let one bad experience stop you from giving pediatric injections.

A PNP can work NICU, but it is extremely rare. Most prefer (and with good reason) to hire NNPs to care for their critical babies. Most PNPs if hired will work more with 'feeder/grower' babies and well-baby. In areas were NNPs are rare or unavailable, a PNP may be hired to work NICU even though the scope of practice there is crossing over more toward NNP. For instance, I recently saw a job opportunity in rural Alaska looking for a PNP to work with pediatrics, their NICU, and the well-baby nursery. As an acute care NP, I learned a lot of what NNPs will do - art line/PICC line insertion, lumbar puncture, vent management, similar diagnostic evaluation, etc. However, there is gray-area there. My scope is from birth until 21 years. Even though a 28 weeker is technically within scope after birth, they still would receive more specialized care from someone who only works with premature infants. Just as the kiddos I work with get more specialized care from me only doing pediatrics than someone who may do more rounded family care. I've only known one nurse to complete both degrees. She works NICU and uses well-baby and teaching to count toward her pediatric practice. She just as easily could have done NNP and been done. She probably would have if she had not received her PNP first. You have to keep up with different continuing education requirements for each degree and you have to pay for two different certification renewals with each re-cert. Most PNPs will re-certify annually because that's what the PNCB requires. I'm not familiar with the NNP re-certification requirements, but I know as far as the continuing education hours it's similar.