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.

[leslie :-D]

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.

i do use the lidocaine gel but the facility did not have (nor order) any coudes.

i used to refrigerate them also, before attempting to insert.

what are filiforms???

[plumrn, BSN, RN]

Another one here who is humbled by NG tube insertions. Especially on resp or cardiac pts. One of the 1st ones I ever inserted accidentally went in the trachea, and the pt started to cough, and lost their breath briefly. They coughed and gagged and became cyanotic. It was just for a moment, but it scared me so much, I now have a phobia about them!

And the little trick of getting them to swallow water as you pass the tube, makes me scared that I will pass the tube in the trachea again, and cause them to aspirate the water. I feel so relieved whenever I do pass one successfully.

[thanatos]

i do use the lidocaine gel but the facility did not have (nor order) any coudes.

i used to refrigerate them also, before attempting to insert.

what are filiforms???

I can't imagine not having coudes. As soon as I hear the words "prostate problems" coupled w/ urinary retention, I reach for a Coude. Filiforms and followers are tools urologists have in their bag of tricks to sequentially dilate a strictured urethral.

Here are a couple of photos of them:

http://www.wellspringurology.com/filiforms.php

And here a website briefly describing their use:

http://www.gpnotebook.co.uk/cache/-348848083.htm

[leslie :-D]

I can't imagine not having coudes. As soon as I hear the words "prostate problems" coupled w/ urinary retention, I reach for a Coude. Filiforms and followers are tools urologists have in their bag of tricks to sequentially dilate a strictured urethral.

Here are a couple of photos of them:

http://www.wellspringurology.com/filiforms.php

And here a website briefly describing their use:

http://www.gpnotebook.co.uk/cache/-348848083.htm

thanks thanatos.

it makes sense but does seem risky.

and you have to remember, that i work in hospice and except for the newer forms of meds, i don't have access to the latest and the greatest...you make due with what you've got.

leslie

[kat911]

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

For the women and the baby girls put a Qtip on your sterile area and use it to find the meatus, taught to me by an older nurse, works pretty good. When trying to cath the LOL's sometimes you need to try the Brail method, somethimes the meatus is up under the pelvis and only way to find it iw with your finger, then guide the cath on in to position. Try doing that while the LOL is screaming RAPE in your ear. :rotfl:

[mattsmom81]

Critical thinking is the most difficult skill to acquire. It involves a level of experience to do this appropriately. Not just book learning. The classic patient you see in the textbook is not likely to materialize in real life; and good judgment is not gleaned from reading an assignment in a book. Tell this to college professors. though....