What do you think is the MOST difficult clinical skill to acquire in your experience?

[Roland]

Do you have any tips on improving someone's chances of "mastering" this skill? My guess is that it might be blood draws, from the old, obese, and dehyrdrated. If not that perhaps accessments, given that this is a skill that can expand almost infinitely depending upon your knowledge base, and observational abilities that CAN expand with accumulated experience.

[fairyprincess2003]

trach care by far. I don't know why, it always made me nervous...also the correct techniques and testing. I still don't feel comfortable doing it. I also always get very paranoid about keeping the pt oxygenated!!!

[leslie :-D]

i can catheterize any type of woman absolutely no problems.

but to catheterize a man with an enlarged (i'm talking huge) prostate where it's obstructing the bladder neck, is a tough one for me.

one time i had to have a doctor do it, and he completely traumatized the patient and his urethra, very bloody.....literally rammed it an after sev'l attempts.

and working in hospice, i'm asked to catheterize alot.

sometimes i'll spend close to an hour on those w/advanced prostate ca.

leslie

[sleepless in norman]

Hemodynamic Wave Form recognition and interpretation. :uhoh21:

[newfloridaRN]

ORamar...

are you in pittsburgh? where do you work, if you dont mind my asking? :)

[healingtouchRN]

I agree with Teeituptom, patience is the hardest skill, & am continually working on this craft. Another on is IV's, which took my working in the ER for years to really get it right. The third is making a really pretty cast. I am sooooo not the ortho tech or ortho RN so my casts were pretty ugly. Really is an art to it! :balloons:

[mscsrjhm]

Found the most difficult is those darn wound vacs. Trying to change the dressings on large wounds in ackward places. Need 6+ hands, and go through many, many sheets.

Playing "find the meatus" on contractured female patients isn't a breeze, either. Trying everything... back, right side lying, left side lying...

I will not even ATTEMPT to cath a male without a co-worker present. Once watched a terrible nurse cause hemmorhage, and we were then advised by an "old" Doc to always have another in the room when you cath a male. He said there is a million to one chance of perforating a weakened area, but don't take that chance. So, this was a habit that we got into. Always have assistance with a male.

[leslie :-D]

I will not even ATTEMPT to cath a male without a co-worker present. Once watched a terrible nurse cause hemmorhage, and we were then advised by an "old" Doc to always have another in the room when you cath a male. He said there is a million to one chance of perforating a weakened area, but don't take that chance. So, this was a habit that we got into. Always have assistance with a male.

i've never heard about perforating a weakened area but there is great potential for urethral trauma (not perforation, more abrasive) when you have just a tiny tiny opening in the bladder neck and you're there for God knows how long because it is 80% obstructed by the prostate.

i've had mds get upset with me because i had them catheterize these challenging male patients....

when someone is that obstructed, i think the procedure should be done under fluoroscopy so at least you can see where you're tunneling the catheter.

as for those contracted little old ladies, i've mastered that one chrisco woman...but have discovered that there are plenty of anatomically incorrect ladies. always bring 2 caths w/you.

leslie

[mscsrjhm]

You are right... wrong terminology. My brain isn't working well today. Blaming the kids.

Hemmorhaging from the member is a nasty thing to see. Terrible nurse. We got into the habit, kinda like it to this day.

[TiffyRN, BSN, PhD]

IV's on the neonates. I used to be a go-to person when I worked with adults, I'm totally humbled now.

Replacing an ostomy bag on a neonate. I used to do just fine with adults plus most of them had had them for years and gave me tips on what worked best with them. On the babies, (and most of them are small, less than 4 pounds) I have trouble cutting the hole without puncturing the bag, cleaning and prepping the area without traumatizing their delicate skin, dealing with a constantly oozing stoma (guess what kind of poo you get from breast milk?), and most importantly, getting the stupid thing to STICK! Oh, and one of our surgeons doesn't like the mucous fistula to be inside the bag and then he locates it smack up against the stoma and somehow we are supposed to ostomize that????!!!!

[kidluvinRN]

Dealing with combative patients and difficult families. I can handle clinical mechanical tasks just fine...with practice, they all become old hat soon enough...but...dealing with violent or difficult people.......

I always find the above toughest for me!

Thats funny; I am the complete opposite. I'm good with difficult people and situations; but caths, blood draws, cardiac technical stuff, I always sweat it!...probably just dont do it enough. My comfort zone is respiratory. Vents took awhile to understand, but then like you say "old hat".

[txspadequeenRN, BSN, RN]

Oh I so agree with the NG insertion ...... Thats mine right there NG insertion... Horrible..

Toughest was subtle visual cues, like color of skin, and patients not looking right, but once it came to me that skill has been extremely valuable.

Worst skill is NG insertion. No matter how you do it, it's a vile procedure for the patient to go through, and if there doesn't seem to be any skill to it- if it won't go after 3 tries it probably won't go no matter who does it or how.

I much prefer a tough IV stick because you can work and get better with time.

[thanatos]

i can catheterize any type of woman absolutely no problems.

but to catheterize a man with an enlarged (i'm talking huge) prostate where it's obstructing the bladder neck, is a tough one for me.

one time i had to have a doctor do it, and he completely traumatized the patient and his urethra, very bloody.....literally rammed it an after sev'l attempts.

and working in hospice, i'm asked to catheterize alot.

sometimes i'll spend close to an hour on those w/advanced prostate ca.

leslie

I have pretty success in these cases using lidocaine jelly and a coude catheter. Just apply steady pressure and generally the stiff curved tip of the coude will slide past the obstruction. I have had a couple cases where this did not work and a urologist had to come in and use filiform (sp?) followers in order to get the catheter in.