Philly85

Hi everyone, I'm a nursing student and I just had an exam last week where a question on the exam asked about factors that might increase pre-load. One of the answers was tricuspid stenosis, so I did NOT pick that one, b/c I understand pre-load to be the volume in the ventricles at end-diastole, nothing to do with the volume in the atria. Therefore, if there is tricuspid stenosis, LESS volume would be getting to the right ventricle, thus less pre-load. However, she picked it as a correct answer (it was a select-all-that-apply type question). I got all of the answers on that question right, except for that one. Can you take a look at the below e-mails and tell me if I'm completely off base? Am I right or wrong? I just sent the most recent e-mail and am waiting for a reply. Today is Sunday night and we have class Tuesday night, so not sure if I'll get a reply before then or if she'll just talk to me in class. I'll post the e-mails in order: Hi Dr. XXXXX, I just wanted to follow up with you on one of the questions from the exam last night that you went over in class afterward. For the question regarding which factors would elevate preload, you had tricuspid stenosis as one of the correct answers. I didn't put that as one of the answers because I though that preload was only in reference to the ventricles, not the atria. Therefore, my thought process was that the tricuspid stenosis would decrease the amount of venous return getting back to the right ventricle, thus decreasing preload, not increasing it. Slides 12-17 in the powerpoint "Concepts of Cardiac Output" seem to mention only the ventricles in relation to preload and not the atria and the textbook on page 218 states "Preload, then, is the volume of blood in the left ventricle at the end of diastole." Page 255 states "Preload is the volume in the ventricle at end-diastole." I know we are only supposed to use the textbook as a reference, but a few other websites I looked at also seem to only mention the ventricles. Am I looking at this the wrong way? I hope this doesn't come off the wrong way, I'm just confused and want to make sure I have this correct in my mind. Thanks in advance for your time. Sincerely, XXXXX ================================================== Dear XXXXX, I explained this principle in class. Just step back and think about this. Blood moving through the heart. Blood moves through both the atria and the ventricles. So while we emphasize the ventricles because that is what cause the bigger pump or push forward it is also important to think of the atria because if the atria don't fill the ventricles the ventricles have nothing to pump. The heart has to work as one, with both pieces working together. Don't take things so literal. I can see you are a literal thinker or like things black and white. The body is abstract and you need to look at the broader picture. Think of this analogy. If you are walking through double doors. The 2nd door (the ventricle is working) but the 1st door you can't really get through because the door only opens part way. Then only 2 people will get through vs 6. Those people that don't get through will cause a back up (in the atria) this will increase people volume as in the heart would increase blood volume. It still increases volume or preload. The heart must be looked at as one. Not in isolation. This is why I draw the picture on the board. Plus where does the CVP to measure preload sit? Prior to the R atria. So the way it will sense increased volume or preload is if it increases in the atria right? I hope this helps in clarification. Dr. XXXXX Hi Dr. XXXXX, Thanks for getting back to me. My issue isn't that I don't understand the concept or that I'm not able to think abstractly or in a broader sense, my issue is the definition of pre-load by the textbook vs the definition you are using for the exam, because the definition used changes the answer to the exam question. If we go by the textbook (and we as students have been told to go by the text for as long as we've been in the program), preload is the volume in the ventricles at end-diastole (page 255). Though I understand that the pressure in the atria (or just above it, as with CVP) is a good indicator of preload, from what I can tell from the textbook and other various sources, it is not the actual definition of preload itself, which seems to only refer to the ventricles. I really have made a good-faith effort to find any reference in the textbook or anywhere else where it states that there is atrial preload (in addition to the established ventricular preload), and I have not been able to come up with anything. Page 698 of the text states: "The CVP represents the filling pressure of the right atrium and is a measurement of right ventricular preload." This seems to reinforce that, although atrial pressure or CVP is a good measurement for pre-load, it is not where the actual preload itself is located, which would be the ventricle. The only reason I make this differentiation is because of what follows next. On page 241 of the text, in table 14-1, it defines CVP as "Pressure created by volume in the right side of the heart. When the tricuspid valve is open, the CVP reflects filling pressures in the right ventricle." However, the exam question was about a stenotic valve, so the CVP wouldn't reflect the right ventricle (aka preload) in this case, it would actually be the opposite. Further, on page 256 of the text, in reference to mitral valve stenosis, it states: "Mitral Stenosis. Pathology of the mitral valve-stenosis or regurgitation-alters the accuracy of PAOP and PADP as parameters of LV function. In mitral valve stenosis, LAP and PAOP are increased and cause pulmonary congestion; however, these elevated values do not reflect the LVEDP because a stenotic mitral valve decreases normal blood flow from the left atrium to the left ventricle, decreasing LV preload and consequently lowering LVEDP. A nonstenotic mitral valve is essential for accurate readings because a narrowed mitral valve increases LAP, PAOP, and PADP in the presence of a normal LVEDP." Even though it's talking about the left side of the heart above and the question on the exam was talking about the right side of the heart, I would think the same principle would apply. Again, this is all assuming that, strictly defined, preload is referring to the volume only in the ventricles at end-diastole and not the atria. As I mentioned before, I cannot find any instance where it is stated that the atria also have a "preload", only that the CVP/RAP are a good indicator of what the right ventricular preload will be when the tricuspid valve is open. I truly do not remember you saying anything about atrial preload vs ventricular preload in class and I don't see anything in the slides or the text. Though I fully understand the relationship between CVP/RAP and right ventricular preload, if preload itself is defined as only occurring in the ventricles (as evidenced by the text), then I feel that the exam question should be changed to NOT include tricuspid stenosis as something that increases preload, as it would actually be decreased. Sorry for the long-winded e-mail and thanks again for listening and for your patience. See you in class Tuesday and I hope you have a great evening. Sincerely, XXXXX ================================================= That's it for now. Am I crazy or am I right? I really like my professor and she's really amazing usually, but I really feel like I'm right on this one, if we are going by the textbook. Of course, I'll also humbly accept that I'm totally wrong, if that ends up being the case. Thanks everyone!

Hi everyone, I'm a nursing student and I just had an exam last week where a question on the exam asked about factors that might increase pre-load. One of the answers was tricuspid stenosis, so I did NOT pick that one, b/c I understand pre-load to be the volume in the ventricles at end-diastole, nothing to do with the volume in the atria. Therefore, if there is tricuspid stenosis, LESS volume would be getting to the right ventricle, thus less pre-load. However, she picked it as a correct answer (it was a select-all-that-apply type question). I got all of the answers on that question right, except for that one. Can you take a look at the below e-mails and tell me if I'm completely off base? Am I right or wrong? I just sent the most recent e-mail and am waiting for a reply. Today is Sunday night and we have class Tuesday night, so not sure if I'll get a reply before then or if she'll just talk to me in class. I'll post the e-mails in order: Hi Dr. XXXXX, I just wanted to follow up with you on one of the questions from the exam last night that you went over in class afterward. For the question regarding which factors would elevate preload, you had tricuspid stenosis as one of the correct answers. I didn't put that as one of the answers because I though that preload was only in reference to the ventricles, not the atria. Therefore, my thought process was that the tricuspid stenosis would decrease the amount of venous return getting back to the right ventricle, thus decreasing preload, not increasing it. Slides 12-17 in the powerpoint "Concepts of Cardiac Output" seem to mention only the ventricles in relation to preload and not the atria and the textbook on page 218 states "Preload, then, is the volume of blood in the left ventricle at the end of diastole." Page 255 states "Preload is the volume in the ventricle at end-diastole." I know we are only supposed to use the textbook as a reference, but a few other websites I looked at also seem to only mention the ventricles. Am I looking at this the wrong way? I hope this doesn't come off the wrong way, I'm just confused and want to make sure I have this correct in my mind. Thanks in advance for your time. Sincerely, XXXXX ================================================== Dear XXXXX, I explained this principle in class. Just step back and think about this. Blood moving through the heart. Blood moves through both the atria and the ventricles. So while we emphasize the ventricles because that is what cause the bigger pump or push forward it is also important to think of the atria because if the atria don't fill the ventricles the ventricles have nothing to pump. The heart has to work as one, with both pieces working together. Don't take things so literal. I can see you are a literal thinker or like things black and white. The body is abstract and you need to look at the broader picture. Think of this analogy. If you are walking through double doors. The 2nd door (the ventricle is working) but the 1st door you can't really get through because the door only opens part way. Then only 2 people will get through vs 6. Those people that don't get through will cause a back up (in the atria) this will increase people volume as in the heart would increase blood volume. It still increases volume or preload. The heart must be looked at as one. Not in isolation. This is why I draw the picture on the board. Plus where does the CVP to measure preload sit? Prior to the R atria. So the way it will sense increased volume or preload is if it increases in the atria right? I hope this helps in clarification. Dr. XXXXX Hi Dr. XXXXX, Thanks for getting back to me. My issue isn't that I don't understand the concept or that I'm not able to think abstractly or in a broader sense, my issue is the definition of pre-load by the textbook vs the definition you are using for the exam, because the definition used changes the answer to the exam question. If we go by the textbook (and we as students have been told to go by the text for as long as we've been in the program), preload is the volume in the ventricles at end-diastole (page 255). Though I understand that the pressure in the atria (or just above it, as with CVP) is a good indicator of preload, from what I can tell from the textbook and other various sources, it is not the actual definition of preload itself, which seems to only refer to the ventricles. I really have made a good-faith effort to find any reference in the textbook or anywhere else where it states that there is atrial preload (in addition to the established ventricular preload), and I have not been able to come up with anything. Page 698 of the text states: "The CVP represents the filling pressure of the right atrium and is a measurement of right ventricular preload." This seems to reinforce that, although atrial pressure or CVP is a good measurement for pre-load, it is not where the actual preload itself is located, which would be the ventricle. The only reason I make this differentiation is because of what follows next. On page 241 of the text, in table 14-1, it defines CVP as "Pressure created by volume in the right side of the heart. When the tricuspid valve is open, the CVP reflects filling pressures in the right ventricle." However, the exam question was about a stenotic valve, so the CVP wouldn't reflect the right ventricle (aka preload) in this case, it would actually be the opposite. Further, on page 256 of the text, in reference to mitral valve stenosis, it states: Mitral Stenosis. Pathology of the mitral valve-stenosis or regurgitation-alters the accuracy of PAOP and PADP as parameters of LV function. In mitral valve stenosis, LAP and PAOP are increased and cause pulmonary congestion; however, these elevated values do not reflect the LVEDP because a stenotic mitral valve decreases normal blood flow from the left atrium to the left ventricle, decreasing LV preload and consequently lowering LVEDP. A nonstenotic mitral valve is essential for accurate readings because a narrowed mitral valve increases LAP, PAOP, and PADP in the presence of a normal LVEDP. Even though it's talking about the left side of the heart above and the question on the exam was talking about the right side of the heart, I would think the same principle would apply. Again, this is all assuming that, strictly defined, preload is referring to the volume only in the ventricles at end-diastole and not the atria. As I mentioned before, I cannot find any instance where it is stated that the atria also have a "preload", only that the CVP/RAP are a good indicator of what the right ventricular preload will be when the tricuspid valve is open. I truly do not remember you saying anything about atrial preload vs ventricular preload in class and I don't see anything in the slides or the text. Though I fully understand the relationship between CVP/RAP and right ventricular preload, if preload itself is defined as only occurring in the ventricles (as evidenced by the text), then I feel that the exam question should be changed to NOT include tricuspid stenosis as something that increases preload, as it would actually be decreased. Sorry for the long-winded e-mail and thanks again for listening and for your patience. See you in class Tuesday and I hope you have a great evening. Sincerely, XXXXX ========================================= That's it for now. Am I crazy or am I right? I really like my professor and she's really amazing usually, but I really feel like I'm right on this one, if we are going by the textbook. Thanks cardio people!

So, first of all, just want to say thanks for listening to anyone who reads this VERY long post. I just really need to get this off my chest, as it is really negatively affecting me. I'm currently in my 2nd to last quarter in my program and my clinical instructor just completely dressed me down today after post-conference after everyone else had left. Today was only our second time together and I already did not get off to a good start with her last time. She is of the mind-set of being very self-sufficient and taking charge and not asking lots of "obvious" questions, since we are "seniors" (I'm not in a traditional 4 year program, it's a 2nd degree accelerated program). We have clinical pretty infrequently (one or two 12 hour shifts every OTHER weekend, depending on the quarter), as it is for working adults. I'm a very detail-oriented, conscientious person, and I really need to do something about 5 times and on an consistent basis before I feel really comfortable with it. The problem is that we have clinical in such short, condensed bursts and then a two-week break in between that I never really ever get truly comfortable with anything. Not to mention the fact that we only have 5 total clinical days at any one site in the entire quarter, so I never really get comfortable with the staff, the layout, their equipment, etc. That leads me to ask lots of questions, just to make sure I'm doing everything right. Certain things, like vitals, bed baths, bed-making, Accuchecks, etc I'm good with, but certain other skills like IM or subq injections, foleys, trach suctioning, I've done maybe a handful of times, and trach suctioning not until my most recent clinical the other week. I could already tell our first day together the other week that she is not a fan of my questions and I can kind of see where she is coming from, but I just don't want to make a mistake and I want to make sure that I'm truly learning the correct way to do something or not placing a certain thing down the wrong way, etc. I'm very detail-oriented and I want to do things the way they are supposed to be done, so...I dunno, some people can't handle me sometimes. But when I DO learn it the correct way and have it down, I'm amazing at it and never ask the question again. Well, anyway, so I'm already off to a bad start last time and I've been dreading this clinical today for the past 2 weeks b/c I can tell she is just not feeling me. But I tell myself to make the best of it and make it work and just do my best. Of course, I get there 10 minutes late (supposed to be there at 6:30 am, got there at 6:40 am b/c they were doing construction around my train station and I had to walk the long way around). I was so anxious to get to the desk that I forgot to stop at the locker room and drop my back-pack off. "Are you supposed to have your back-pack in here?" Totally my bad, I should have left home a little sooner and, yeah, I forgot to stop at the locker room. No big deal. Then we had a combative patient and they wanted to get mittens for him, but he had since calmed down b/c we gave him a sedative. Anyway, I still went and got them from another floor (our floor was out) and I asked if she wanted me to put them on right now when I got back. "When else would you put them on, he's combative, right?" Well, yes, but calmed down some, but I can see your point, he might become combative again, OK, I'll go put them on, makes sense. Pt was very cooperative and even held out his hands perfectly for me to put them on. Smart thinking b/c he WAS combative a few hours later. Lesson learned. Then, I was in with my pt with my nurse and my instructor called in and told me to go on break when I was done. In my head, I honestly heard the word "lunch" b/c in all of my previous clinicals, "break" meant our 1 hour lunch. We never really took 15 minute breaks, just the 1 hour lunch. It was 11:15 am, a little early, but whatever, I was hungry, wasn't gonna argue. Go to lunch and come back at 12:15, chilling for a little bit on the computer trying to fill out our worksheets we have to fill out for the day and she comes by and asks me where I've been and that I missed the 12 noon med pass (she had wanted me to do the insulin injection on the 1 patient). ****, I totally forgot that she wanted me to do that, and I totally OWN that, that was my bad. I tried to explain that I could have sworn she said lunch and that I didn't even realize we were supposed to be taking 15 minute breaks (she apparently did say this the first day, but I don't remember - again, my bad, I'm working against a year and a half of usually just taking 1 hour lunches during clinical, so I forgot). It was literally the most HONEST mistake I've ever made in my life. I then asked my nurse I was with a bit later what she remembers our clinical instructor saying about break vs lunch, not because I thought she was wrong, but because I really thought I heard the word "lunch" and wanted to make sure I wasn't going crazy. She told me she heard the word "break" and I said "OK, thanks, I must be going crazy, lol", like didn't make a big deal. Well, this nurse apparently told the instructor and that did not go over well. Throughout the day, we are supposed to get done our 4 page worksheet/care-plan and myself and my whole cohort are used to not having to hand that in until the next clinical day, not the same day. So we're all kind of struggling throughout the day to get it done so we can hand it in at the end of the shift. I did take several 20 minute breaks to get portions of it done throughout the day. However, I was definitely in my patients' rooms throughout the day, pitching in with everything, doing anything when asked. Well, I guess my one patient had multiple issues during a few of my downtimes, needed to be changed multiple times, was combative again and my partner (we worked in pairs) ended up having to deal with it all several times. Apparently, I was "nowhere to be found" (I was at the computer at the end of the hall b/c the other computers near my patient's room were taken). My partner is truly amazing and so helpful and I love her, so this is not anything against her at all. My one nurse then asked me if I could make sure we definitely got the pt from his chair back into his bed before we left for the day, b/c she had a new admit and had to do q30 min assessments. Had to use a Hoyer lift to get him into and out of the chair, so it was a bit more time-consuming of a task. I assured her we would. Well, we then got pulled into doing a bunch of stuff for our other combative patient so that got a bit delayed, but we still had about an hour left until we were leaving and we were just about to do it. But she came in anyway and started to do it herself and pulled in a few of my other classmates. I apologized and said I was about to start it, but she said it was fine. That was also relayed to the instructor. (Side-note b/c I just remembered, apparently, getting him into the chair earlier in the day also happened during one of my 20 min breaks when I was nowhere to be found, AKA down the hall). Finally, while in the middle of heating up a heating pad in the microwave for a pt, one of the techs asked me to go put the leads back on a patient that had fallen off. I (stupidly) said "Oh, I don't quite remember how to do that" and DIDN'T follow it up with "but I'd be happy to get someone to refresh my memory and go do it", and she had kind of already drifted away before I realized my mistake. I found her about 1/2 hour later and apologized and said I was sorry, it just slipped my mind and that I wasn't trying to avoid doing work. But she had already told the instructor. So anyway, very long story short, my instructor (in front of everyone) tells me to stay behind at the end of post-conference. Once we're alone, she tells me she is going to send a clinical communication to my course chair about me taking lunch early. She then said how she noticed I was slacking off and not being a team player and not wanting to chip in and then all of the other stuff the nurse/tech relayed, but wasn't going to relay THAT particular info in a clinical communication and wouldn't send me to remediation (though she could have) and would give me a second chance next time. I said thank you. I was truly shocked, since I really felt I had pitched in and really tried to do a good, conscientious job today. I even became teary/emotional (damnit) and said I had always gotten really good feedback at previous clinicals (I have) and I was really surprised to hear this and that I had really tried to be helpful/a team player today. I was so stressed about getting our worksheet done that maybe I could have spent more time in the room, but I really was only working on them for like 20 minute spurts (and not a whole lot of them throughout the day, maybe like 5 or 6 total). I truly didn't know how else I would have gotten it done otherwise. And not all of my classmates DID get theirs done. I suppose I should have made patient care a priority, but she basically said that the worksheet was just as important and I needed to figure out how to get that done in addition to not shirking my patient care responsibilities. I KNOW that I made stupid mistakes today and I TOTALLY own up to that and I will absolutely be more conscientious next time, but it's just so disheartening to have someone have a certain opinion about you when you really did try your best and just made honest mistakes. I am now so terrified of going back next time and getting the same feedback and having to go to remediation, etc. Maybe I'm just having a rough few weeks, but now I'm worried that this is going to be an ongoing issue and am feeling really disheartened, especially after usually doing so well in clinical. Does anyone have any advice or words of wisdom? How can I get better at getting these worksheets done and not "disappearing" for 20 minutes when there is no available computer station near my patient's room? I'm sorry if I sound like a huge complainer. I totally own up to my mistakes and I just want to get BETTER and help out as much as possible. I want to be an AMAZING nurse and I just feel so stressed about this right now. Thanks for listening, you guys.

Hi Everyone, I am still in nursing school and was hoping for some tips/tricks when you go into an isolation room. I know the correct order for donning/removal of PPE and that isn't really my issue. My issue is when it comes to my stethoscope, notepad/pen, and also the computer. I know that a lot of rooms have their own stethoscopes for pt's who are on isolation, but a lot of times, those stethoscopes are lower quality and you can't hear well. All the doctors and nurses I've seen tend to use their own. How do you go about using your stethoscope and then cleaning it afterwards when in an isolation room? Do you keep it tucked down under your gown until you need to use it and then pull it out when you need it and then tuck it back in when you're done? Or do you keep it on the outside the whole time? Is there a "graceful" way to pull it out from the gown and tuck it back in? I feel like every time I've done this, I look like a complete freak who is fighting with an invisible ghost underneath my gown, lol. When done, what's your process for cleaning it and washing your hands in order to avoid contamination, etc? Do you do it while you're still in the room or wait until you leave? Do you put on new gloves before wiping it down? Or do you not need to do that as long as you wash your hands after? What type of wipe should you be using to wipe down your stethoscope? The one with the blue top or the red top? I feel like the red-top one is stronger and I'm not sure if this will damage my stethoscope. In regards to note-pad/pen, sometimes I need to write something down, then I feel like I'm contaminating those things if I've already touched the patient and then I have to wipe down my pad/pen when I leave. Should I take off my gloves, hand sanitize, write, then sanitize, then put on new gloves? That seems excessive and very "interruptory" (I know that's not a word). However, I am worried if I wait until I'm done that I'm going to forget what I needed to write down. Also, do you take off your gloves and then put on clean gloves before typing something into the computer if there is a computer in the room? Or do you use the same gloves (I'm thinking this is def a no-no and I def don't do that) or do you take off your gloves and just use your bare hands? How often does environmental services tend to clean the keyboards? Or, again, does it even matter as long as you're washing your hands/sanitizing when you leave? I just get all confused/tripped up when it comes to this area. I see people doing so many different things and I want to do it the right way to protect both myself and all of the patients on the floor. Sorry if this seems stupid/common sense, but I just can't get down a good routine for this. Any advise or tips/tricks would be very welcome. P.S - I know I mentioned above that I don't have an issue with donning/removal of PPE, but now that I think of it, sometimes I see people take off their gloves last, so that they don't have to touch their gown. I see why this would make sense, especially if you don't have to wear a mask, since it seems like the only reason they want you to take off the gloves first is so that you aren't touching your face mask and getting close to your face with a dirty glove. Even with a face-mask, sometimes I am tempted to leave my gloves on until the end, so that I don't have to touch the gown, especially if the gown is a bit soiled or the linen thing in the room is full and you end up touching the other gowns in there by accident when putting yours in. Again, any advice/help is greatly appreciated! Thank you!

In addition to being in Nursing School, I also work administratively at a major hospital. I often see either surgeons or OR nurses or scrub techs in the cafeteria or just walking around the hospital or out in the courtyard wearing their scrub caps (disposable ones) or surgical gowns. I'm confused by this...what is the point of wearing it once the case they were in previously is completed? It's not like they can reuse the cap or gown. Wouldn't it just be easier to take it off once they have completed the case? Please help me understand...thanks.

I'm currently doing it right now. Work full time Mon-Fri 8:45 - 5:15, then class from 6 - 9:50 Tues/Thurs, then clinical every other weekend, both Sat and Sun for 12 hours. I'm not gonna lie, it's really freaking hard. I'm more than halfway done and I'm STILL trying to get better at forcing myself to do a little bit every day and not get behind. If it weren't for the tuition assistance, I wouldn't be working. Good luck!

I"m LOL'ing, thanks for the laugh!

Ugh, the dreaded head to toe. Please know that you are not alone. When I started my first clinical, those very words would fill me with ice-cold fear. It absolutely DOES get better with practice, you really just need to push through it and develop a consistent system that you do the same way EVERY time and never deviate from. I'm still in nursing school (a little more than halfway through), but this is basically what I do from time of intro through head to toe: Walk into room: Hi, I'm Philly85, I'm a student nurse from So and So University. I'll be helping out Nurse So and So with your care until 7 pm tonight. How are you feeling? (Respond appropriately to their answer and have general 1-2 minute convo to build a rapport). Is there anything I can get you right now? OK, I'll go ahead and grab that for you. Would it be all right if I get your vitals and do a quick assessment on you when I come back? Ok, great, I'll be right back. AND ACTUALLY COME BACK SHORTLY - DON'T GO HIDE IN THE BATHROOM FOR 30 MINUTES FREAKING OUT ABOUT HOW YOU ARE GOING TO DO YOUR ASSESSMENT (yes, I did this several times in the beginning, lol...) Get them whatever they need, come back (hand hygiene before coming into the room) and give them whatever was requested. Putting on gloves as you say --> "OK, as I mentioned earlier, I'm just going to get your vitals and do a quick assessment. Can you tell me your name and DOB? (Verify what they state matches wristband). --> Don't ask them if it's still a good time (unless they are eating breakfast or something). If you do, they might put it off, etc. You need to get your assessment done, the sooner the better. Get vitals, including pain level (I'm assuming you can do this by now) Neuro: AAO x 3: You may have already determined their status just by having that 1-2 minute convo with them when you first entered the room. If not, then just ask the basic questions. "Can you tell me your nurse's name or my name (don't ask them their own name, that is too easy and is not a good indicator of if they are actually oriented to person), do you know where you are/what floor you're on, what is today's date/who is the president?) PERRLA using penlight. Cardinal fields of gaze if not already determined by simply seeing that their eyes tracked you easily throughout the room previously. CV: Auscultate heart sounds at all five points with diaphragm and bell - Apical heart rate if you are feeling fancy Pulm: Anterior/Posterior Breath sounds GI: Auscultate bowel sounds FIRST, then palpate Now all of your stethoscope stuff is done Check B/L radial pulses for amplitude, cap refill on index fingers, and upper extremity strength testing Skin: You've already been assessing the skin up until this point with everything you've been doing, but now lift up blanket and inspect the lower extremities. Feel for skin temp with backs of hands going down their shins, then check for edema with thumbs going down their shins again. Check pedal pulses, cap refill on big toes, heels for skin breakdown, lower extremity strength testing. "OK, everything looks good" (if it does), or if something is off, let them know, but that you will have their nurse come and take a look. "Thank you for letting me do your assessment, is there anything else I can get you? No? OK, well we'll be back in at 8 am to give you your morning meds." If they are incontinent, check their skin for breakdown whenever you change them. Don't let the CNA's do it all the time, you need to get in there to make sure you are assessing. If not incontinent, they are more likely to be up and walking or getting onto a commode. Check their posterior skin if you are up and walking them/assisting them during these times. Seems to work pretty well for me, anyway. Some people like to stick strictly with the systems and go back up and down the body (strength testing all at once, cap refills all at once, pulses all at once, etc), but I find it much easier to literally stick to HEAD TO TOE - otherwise I forget stuff. P.S. - Now is also a good time to ask them if they'd like to move from bed to chair for a little while (maybe have breakfast in the chair while watching the morning news?). Help them change into a new gown once in the chair. Then change the bed linens and spruce up the room a little bit. P.P.S. - This may not all work out as perfectly as the above, but the key is to get in there and get this done AS SOON AS POSSIBLE. There's nothing worse as a student nurse than the feeling of knowing that you still haven't done your assessment on your patient and you are putting it off b/c you are too afraid. Just get in there and do it. And then CHART IT in the computer if your site allows you to do so as a student. Don't worry, your nurse will be doing her OWN assessment and will be charting that as well, so you won't be "messing anything up." It may not be perfect, but usually patients are very understanding that you are a student and are learning. The more you do it, the better you'll become. Good luck!!!

What is the "rookie" mistake that actually happened?

Hi all, Current nursing student who is curious about everyone's methods for flushing a line. I've seen some variations, with some nurses actually lightly palpating the area over the IV as the flush goes in and some not doing so. The nurse I was with yesterday during clinical said he just relies on if pt feels any discomfort and if he feels any resistance, as well as visually seeing if there is any disturbance in the area as the flush goes in. Also, the one patient had a wrist IV and the surrounding area was all bandaged up, so he technically couldn't palpate even if he wanted to on that one. So, to palpate or not to palpate, or does it matter? Thanks in advance for your insight! P.S. Different question. Our one pt was getting Vanco IV and we had to give an IV push of Lasix. So, I stopped the infusion, flushed the line, pushed the Lasix, flushed the line again, then reconnected the Vanco and restarted the pump. After I flushed the line the first time, my nurse just held my flush for me while I pushed the Lasix and then handed it back to me in order to flush before restarting the Vanco. If I had been alone, could I have just put the original cap back on the flush and laid it down in between? Or would I use one of those green-topped caps that has alcohol? I forgot to ask him before I left and was just curious.

I spoke w/ our program director and there actually is a volunteer opportunity one night per week for a few hours in a free clinic, so I'm going to see if I can get involved with that. Thanks for your response!

Thank you for your response. I really like that "anxiety in a box" idea, I'm going to have to try that!

Thanks, nice to know I'm not the only one!

Thank you for your support. I had my second clinical there this past Saturday and the instructor was definitely better this time around and I'm not as terrified of her, lol. I think I'll be OK :)

Hi everyone, I just wanted to kind of get this off my chest and was wondering if anyone has experienced/is experiencing the same thing and if it ever gets better? I'm in a part-time nursing program where we only have clinical once every other weekend for one 12-hour shift. This is my 4th quarter overall and my 3rd quarter of having clinicals. I'm very comfortable with all of the theory and have done very well in the classroom, but I really get super, super anxious several days prior to clinical and then for about the first 3 hours of the actual clinical experience. I eventually settle down once I find a groove, but I never really feel comfortable and always feel kind of in the way and stupid. I try to do my best to "dive in" and help with everything, but it really is a crap-shoot. One day, I'll feel like I did a good job and the next day, I'll feel like I just did the basics, but didn't really help my patient very much or was a bother to them, etc. We only get 5 clinical experiences per quarter and then we're onto the next clinical site, so by the time I'm finally starting to feel comfortable, it's time to move on. I learn by doing, so the fact that I only get to really practice one day every other week makes it hard for me to feel comfortable doing assessments on patients and I feel like an idiot trying to get used to the new facility's DynaMap machines. The other day, the patient looked at me like I was an idiot, b/c their machine was so different from what I was used to and it was my first time. I just always feel like I'm "getting used to" everything and don't really have a chance to settle in and feel comfortable. I wish I was able to go to clinicals 3-4 days a week like the students in the full-time program at my school get to do, but I have to work, especially as my employer pays quite a hefty amount towards my tuition. I suppose that's the trade-off, but it's still frustrating. Starting next quarter, we'll actually be having 2 clinicals every other weekend (Sat/Sun instead of just Sat), but those will be at different clinical sites, so I feel like it will not really help me feel settled in, but will at least give me more practice in general. I do practice on my own at home doing pretend assessments out-loud on invisible patients and I review the proper steps in the clinical skills textbook, but it's not the real thing. I'm hoping this feeling is normal and that once I start working, I can finally get into a groove and feel comfortable. I just hate feeling stupid/out-of-place/useless. I have had a few really good clinical experiences, especially last quarter, as my clinical instructor was actually a clinical educator for her career and actually made it a point to take us into patient rooms and hold teaching sessions and really work with us one-on-one. My previous clinical instructor before that and the one I have right now kind of just sent us on our merry way to "help out" the nurses and to "grab her" if we had questions or needed help, which seems like a cop-out to me. She is asking us questions throughout the day and is planning on doing assessments with us in the room this upcoming week, but I have a feeling there are not going to be planned things every week that we are being taught and that she's just doing the assessments with us this upcoming week so she can do our mid-term evaluation. Are my expectations too high from my clinical instructor last quarter or is this the norm? Anyway, I'm sorry, I'm babbling now...If anyone could offer any advice, I would really, really appreciate it. Thanks for listening! :)

I would imagine you could just call the patient, no? Tell your manager and go from there.

If you are doing 24-month, you should definitely be able to hold down a full-time, or at least part-time, job, some of which will pay part of your tuition.

If you are doing 24-month, you should definitely be able to hold down a full-time, or at least part-time, job, some of which will pay part of your tuition.

I'm in quarter 3 of the 24-month program right now and work full-time, one of the main reasons being that I get substantial tuition assistance from my employer. Also, I wasn't sure I could handle the stress of 11-month. You can get financial aid just like any other program, usually 12.5k per year in federal loans and then whatever other private student loans you want to take out (if you qualify credit-wise obviously). As far as working during the 24-month program, it's def doable, but you have to have strong will-power. Your Tuesdays and Thursdays are completely gone (work all day, then class for 3 or 4 hours after) and every other weekend (sometimes both Sat and Sun, sometimes just Sat).

You do NOT have to defer if you are in the 24 month program, as clinicals don't start until quarter 2. You just have to let Ms. Feraud know that you are working on it and let her know where you are in the process. As long as you have it all done before clinicals start, then you are fine. Now, if you are 11 month program and didn't get Hep B yet, then you might be in trouble, as clinical starts right away. I'm a 24-monther currently in quarter 3.

I also have a bit of germaphobia, though not to the extent that you describe, so I can definitely understand where you are coming from. I don't like to shake peoples' hands, touch door knobs, elevator buttons, etc. I'm also a BSN student and currently in my second clinical rotation. During the first rotation, it wasn't that bad because, as you said, you are wearing gloves. However, I do still get anxiety when I have to enter a pt's room that has contact precautions. I am working on my anxiety and I think I'm going to be OK. The more education you have about how things are spread, etc, the better. I do, however, worry for you in your regular life. It sounds like you have a lot of anxiety and compulsions which probably cause you a lot of stress and the last thing a new nurse needs is undue stress! Have you seen a therapist or tried any anti-anxiety medications? I'm not really one to talk, b/c I haven't done so, but I am also not at the level you are at (no offense meant at all). If you really put your mind to it, you can do anything you want to do, just make sure you get as much education as possible and hopefully get some professional help if you feel up to it. Best wishes!

Current BSN student here. I feel pretty embarrassed asking this question, but I know it's important to ask questions, no matter how "dumb" I think they might be. Maybe it's because my mind is just so overloaded with school stuff or maybe it's just the fact that I never really learned about Diabetes as in depth as I thought I had, but here goes... So, I understand that glucose is absorbed into the blood stream via the small intestine and then the beta cells of the pancreas release insulin into the bloodstream to signal the body's cells to bring in the glucose. In class the other day, my Pharm professor was talking about how dangerous hypoglycemia is and that sometimes it may be a result of over-treating with insulin. She was talking about how the brain would not be getting enough energy and the severe repercussions, etc. What I'm having trouble with is...if there was too much insulin, which caused even MORE glucose to be taken up by the body's cells from the blood, then wouldn't the brain have even more glucose than it needed, b/c even more glucose is going into the brain cells? Or are we assuming that the blood containing the glucose hasn't had a chance to circulate up to the brain yet? Is it because most insulin is given with meals to simulate the body's own natural timing, and you are then causing all of the newly formed glucose to be absorbed by cells that are closer to the point of absorption in the small intestine before it has a chance to circulate up to the brain? How fast does blood flow through the body? Wouldn't it get up to the brain pretty quickly? If you give too much rapid-acting insulin with a meal vs say too much of an XR dose that is given throughout the day via a pump, would that be worse? I was too embarrassed to ask in class and feel pretty sheepish asking on here...any help or video links, etc is appreciated. Thanks in advance for being such a great community!

It went away after 1-2 days.

What is an "AA" ?

Just curious as to why you say CRNA's are doomed from now on?