1st week of clinical

[kitten2013]

Hi everyone,

Thursday was my first day of clinical at a long term care facility. Our shift was 0630-1230. Not only was it my first day of clinical at a real facility, it was also my first day to work with real patients. I've never even given someone a bath, let alone care for someone who is sick or disabled. I felt lost the entire time. I didn't know where anything was or what to do when my patient didn't need me. The CNAs aren't too happy about us being there either, but some were extremely helpful.

Anyway...

My first patient is a woman diagnosed with dementia. She is a sweet woman and the morning went great. She ate all of her breakfast on her own and then asked for a shower. My instructor insisted we bathe patients in pairs, which was super relieving because I was so afraid of trying it on my own. After her bath, we dressed her, changed her shoes, and she was free to walk. She likes to walk a lot in the facility, I've heard she's always up and about.

Now it was time to do my assessment, I found her sitting in a chair at the end of the hallway. So I asked her to come with me to do my morning assessment. She was fine with it and came with me back to her room. I got half way through the assessment, when a nurse came in to give her meds. After that, she became irritable and emotional. I finished most of my assessment, as much as she could handle. She started crying about not having transportation to be in so many places at once. I figured she was tired of sitting, so I let her get up and walk. I cleaned up a little in her room, gathered my papers, and headed to the nursing station to fill out my assessment form before I forgot anything.

I looked up to see her crying and walking. My instructor tried comforting her as well as another student in my clinical group, but it wasn't helping any. I went to sit by her and asked her to tell me what was wrong. She told me that the nurse yesterday wouldn't tell her if her blood sugar was high or low and that she might as well be at home if they can't tell her anything. I told her I'll see what I can do to find out about her results. I went to find my instructor and we looked at her records. She hadn't been tested for blood sugar in two weeks, so I told her the most recent test result which was fine. She was happy after that.

I went back to my paperwork and noticed her walking up and down the hallway, (which has exit doors on each end) she was trying to leave. She told me she was looking for Anthony, her grandson. I spent the next three hours trying to get her to rest, she had been walking and standing since her shower 8. She wouldn't let me bring her back to her room to check her briefs because it was personal and she didn't want to use me. I kept telling her she isn't using me, I'm here to help, and I want to help. After that, she just kept saying she'll think about it. She said she hadn't gone to the bathroom, but I couldn't be sure unless I checked. She wasn't willing to go back to her room for oral care either. She just kept saying I have to go now, or let's go. I finally got her to sit down for lunch before I had to leave.

Has anyone worked with a patient diagnosed with dementia and could give me some tips or advice?

I came home and cried because I felt like I did an awful job. I felt stupid and inadequate to be a nursing student. I wasn't able to complete my assessment, nor was I able to check her briefs or provide oral care. My clinical group members seemed to be doing well all day. They were able to help other nurses and had done their assessments smoothly. Why did I have such a tough time?

I could use any advice anyone can give. I will be working with the same patient next week.

[nurseprnRN, BSN, RN]

Now, let's see, here. You are in your first clinical placement, you've never seen or done anything like this before, and ... you're upset because you don't know how to do it yet? If you knew how to do all this already, your faculty would be out of a job. :)

You are fine. You are a new student. We have all had our first demented patient and felt out of our depth, clueless, inefficient, stupid, and upset. Some of us have also had the feelings of being grossed out (eew, naked old people, dirty briefs, oral care...) or bored (my patient told me to go away, she doesn't need me for anything). Or shocked (one of my classmates helped pass breakfast trays our memorable first clinical day and found somebody stone cold dead in the bed).

You're doing fine. Don't worry about what you think your classmates are doing. It may even be that your faculty think you're ready for something a little more challenging than they got-- definitely take that as a compliment. Of maybe they don't know any of you, and they are learning about you in your first clinicals too.

Meanwhile, back at the ranch .... What to do for next week: Breathe. What have you read about Alzheimer's dementia? (Alzheimer's Disease and Dementia | Alzheimer's Association -- check "Care Info by Stages" ) (you're welcome) What stages do people experience as they begin, progress? Do patients often walk, walk, walk? What interventions for emotional outbursts are most useful? If you check some of that, you will feel better about what you are observing in this lady (good observations, by the way, well done!) and what happens next.

:flwrhrts:

[kitten2013]

Thank you for your reply!

I guess it was first clinical jitters. I actually didn't end up having the same patient the week after because she transferred to another facility. I was just so flustered about having a client who was non-compliant, I felt like I didn't know how to handle that type of situation. I still don't know how to handle that kind of situation, especially when all I'm trying to do is help.

[nurseprnRN, BSN, RN]

Hi kitten2013,

First thing to remember is we don't use the word "compliant" anymore. It has overtones of following orders (one must comply with a court order, for example). Patients may choose to adhere to a medical plan of care, a nursing plan of care, a physical therapy plan of care, or whatever, and they are entitled NOT to adhere to it.

There are many threads in AN about people frustrated with nonadherent (and, alas, "noncompliant") patients and families. Most have good suggestions for working with these people. Not in terms of fooling them into doing what we want or coercing them into compliance; the best ideas involve figuring out what the problem is (fear? misunderstandings? lack of knowledge? something else?) and then helping to solve it.

Just wanting to help is a laudable place for us to start. However, one important thing to learn is that it's not about what we want, it's always about what they want.