WORST day at clinical- just need a shoulder

[BoonersmomRN]

I am in my final clinical rotation and we are on a regular M/S floor.

Today I walk in and find out one of the pts I had yesterday that I stressed needed more aggressive care ..coded..and died. What a start to the day. Then I was getting report on my 3 pts when the night nurse told me she was " sorry" I had this one patient. I already knew then things would probably go badly but I held out hope ( sometimes they said it's bad but you find it's just fine!).

Ok to start off I was told my patients DX was herpes zoster and then she proceeds to tell me the lady is covered head to toe in red circles. Well I know HZ only appears along a dermatome one 1 side so I was already confused. Then she tells me the lady isnt on contact precautions( what???)...she also has " herpes in her mouth" and a febrile sickness. My report basically STUNK. The lady's temp has been 103-104 and they have no idea why.

So I go check the chart and find out that they basically have NO IDEA what is wrong w/ this lady. They have run every test they could so far and everything is neg. So they were sending her for CT Scan.

They said she had to take oral CT contrast..but once I assessed her I could tell there was NO way this lady could take the oral contrast. She couldn't even swallow her spit basically. I was told she had 0630 motrin but when I looked in the MAR it wasn't signed off..and by then the night nurse was gone and when I told my instructor she said she was pretty sure it was given ( Uh, ok???)

OK now I need to back up. When I walk into her room it looks as if WWII happened. There is stuff ALL OVER THE FLOOR....supplies ( Guaze, syringes, tegaderm, flushes, wrappers,you name it). I was like WTH happened in here and I know it wasn't the pt because she couldn't move. So since our instructor has us doing everything w/ no tech help, etc I had to clean all this up before my instructor walked in and saw this wreck. Then her IV had blown overnight and the IV therapy team had not put in a new line..so the night nurse just left everything hanging..even refrigerated meds....I mean you should have SEEN this room.

So I go to assess her and every time I touched her she just SCREAMED out in pain. It was awful. Her temp was 103 auxillary- so DID she get that 0630 motrin? Who knows....I asked about giving another dose and my instructor said " it's Q6!". SO I was able to get her set up on a cooling blanket( that they had set up w/ her rectally but it wasn't connected..nice.. and some cold compresses.)

I left the room to tell my instructor about my findings and she comes in assesses the lady herself and basically just said " good luck".

Well things just got worse...the lady was incontinent consistently....she was NPO but they wanted her to take her am meds crushed up w/ water in 10CC syringes...she could barely take 1cc every 5 mins....it was god awful. I stressed the need to get these meds in IV form or substitutes but my words seemed to fall on deaf ears.

MIND YOU I have not hardly even had time to see my other 2 pts. *sigh*

Then my lady starts to choke and I had to suction her. Then she is incontinent again. Then she chokes again. This is a constant cycle.

I am consistently updating my instructor and apologizing about why I am so late w. the other 2 but I CANNOT leave this lady's bedside and my instructor was adamant we do this w/ no help.

FINALLY at 930 I was able to get a break to check on my other 2pts and give meds....IV therapy came and put in a new IV line on my lady so I go to see if her Doxycycline is up from pharm but it's not....so I go to the pyxis and pull her IV lasix and my instructor walks up and asks me if her doxy is up and I said no I just checked.....literally 5 MINUTES had passed since I checked..and the next thing I know my instructor is walking up and slamming the doxy down in front of me saying it was there ( NO IT WAS NOT- It's a REFIG med and in a dark bag- and there was NOTHING in the fridge when I checked)...so now I look like an idiot.

So I do my checks and we go in to hang the Doxy and give the Lasix and her new IV that IVT had JUST put in is NO GOOD..and my instructor starts yelling at me that I didnt assess the site 1rst.....I was falling apart inside at this point. Then she is incontinent AGAIN..and chokes AGAIN...the cycle starts again

I pulled my instructor aside and gave her the low down and how this lady is almost 1:1 and I have failed to be available for the other 2 pts and could she perhaps give me some guidance on how to better prioritize b/c to me this lady has been a full priority since we can't use any help.

She was basically " She's tough...get used to it" and walks away.

Anywho..the day got worse...they made me TRY to give her 600 mg Motrin in 30CC oral....even though I stressed over and over that she CANNOT take oral meds...and of course she choked and vomited them all up....I was giving her 1cc at a time because it was ALL she could take and my instructor tells me to push 3CC instead and when I do...she vomits... lovely.

FINALLY they decided she was going to get IV contrast for CT and came and got her. I was FINALLY able to spend more time w/ my other pts ...thankfully I was able to give them their meds on time throughout the day.

It was just an AWFUL day and I feel like an AWFUL failure.....4 weeks from graduation and I have NEVER felt so unprepared and helpless.

At post conference my instructor made me tell the group about the horrendous day and critize myself and then she just ripped me apart. I am normally very cool under fire but I couldn't help but just sit there and almost cry.

I know.. I know...I was awful....but WOW ....T.G.I.F

[canoehead, BSN, RN]

Your instructor was a neglectful and spiteful battleaxe. If you go to her saying you can't get the lady to swallow, and she says just do it, I suggest you ask her to show you how....

The RN or the instructor should have been on the phone to the MD in the first hour for pain meds, and DCing the po meds. I'm disgusted with that hospital.

[NurseLatteDNP, MSN, DNP, RN]

You will be an amazing nurse. Be proud of yourself, the way you handled the situation.

I was going to add, on our floor, you can check in the med pixis if a medication has been taken out. They have a list of all removed meds. I do that when the nurse on a previous shift forgets to sign off her meds.

Good luck in the future.

[suanna]

That lady had no business on a gen MED/Surg floor. The level of care she required was more consistant with a progressive ICU or the like. It sounds like you got no support from your instructor- WHERE WAS THE R.N. assigned to the patient? Stick it out the last 4 weeks but I would make an appointment with your advisor if the school has one. Review the facts and see if they agree you needed more support. That instructor endangered a patient and taught you very little besides the fact that you can't count on the instructor to back you up or help you out! Yes you are going to have days like that in practice but you are not in practice yet. You should expect a hand when you get in over your head. Even new grads would need an assist with that assignment- Heck- I would, and I've been doing this 20+ years. The final tally is those that can do those that can't teach may be the case here. Still 4weeks out and you displayed good clinical skills and managed a difficult patient that was obviously a bit too much to handle by the previous shift RN.

[Logos]

Makes me afraid to go the hospital as a patient- I sure as **** hope someone does not ever use me as a learning experience for a student.

The woman was in pain- thats just neglectful and your instructor should be ashamed of herself- you don't keep a patient in pain to teach someone something how f'd up is that?

Also makes me worry- I have not had any days like that on clinical and if I did I would have to rethink being a nurse- what the hell is up with the no help BS?

Shouldn't everyone help each other and work as a team- seems like a crappy teacher and a crappy hospital.

[Sabby_NC]

Sounds to me you did a fine job prioritizing your work.

That patient sounded like she should have been in a step down unit with more one on one nursing care.

Your Clinical Instructor was down right mean. I know you have to have those stinky days with the good days to learn how to cope etc but she could have been a little bit more empathetic than she was.

To belittle anyone in front of others shows what their character is like.

I do not go for that as a professional person I expect and give respect.

If something needs to be said say it in private.

Her behavior does not belong in a clincal setting.

You can be tough but fair!!

Hang in there may the next few weeks get you through.

Wishing you all the very best in your future nursing career.

You are going to do just fine I feel. :)

[BoonersmomRN]

It doesn't sound like you did bad...you did the very best you could...what could you possibly have done differently?

Can anyone answer this question, because I don't understand something. If you were a licensed nurse already, and you knew this patient could not tolerate oral meds, wouldn't it be within your power to call the doctor or whoever it is who has the authority to change the order?

Was it because you are a student that your superiors were ignoring your assessment of the situation?

Thank you and YES it would be ( and is) within the RN's power to call the Dr and request all the meds be changed to other routes. Our instructor won't allow us to actually *talk* to the RN in charge of our patient other than giving report, etc...so everything we ask for/do is done through her. I stressed this to her over and over- it was QUITE obvious when she was IN the room with me trying to have me push oral meds that the poor woman couldn't tolerate PO...but nothing was done about it..And...well...don't get me started on that

Thanks everyone else. Yes, it is a regular M/S floor. This hospital is in a very, very bad part of the city and to be in the ICU you either have to be riddled with 10 bullet holes or on death's door...I'm really not exaggerating it's pretty sad. Everytime I compare it to the hospital I work at I get really angry on behalf of my pt's. The care is subpar because the ratio's and the acuity is really high. They actually had the night/day nurse only have 2 other pts other than this lady ( so 3:1 when the ratio is normally 6-8:1). Still, she needed 1:1 care. She really needed to be in the ICU- just like my lady from the day before needed to be in the ICU, wasn't- and died. Both of these pts would have been in the ICU where I work...but like I said there is just way too high an acuity here due to the clientele that comes in from the area. It's really, really heartbreaking.

Well next week is a new week. 4 more weeks and I am done so I just have to keep working at it the best that I can..I know I def. learned from this:)

[JBudd, MSN]

All I can say is, if you had been in my clinical group, you'd have gotten help. I keep telling my students that they are students, not nurses (yet!); and as such are not expected to perform at certain levels, 4 weeks to go or not.

You did it right by asking her to help you priortize. When she refused to answer that, you then have grounds to approach your dean and report this treatment. Does the school have a written policy about "no help", or "can only talk to instructor"? Sorry, but not "allowing" you to talk to your RN is just wrong. That nurse is ultimately responsible for that patient, and not being informed about the situation is unethical, not to mention it puts her license on the line. I am responsible for overseeing my students; the staff are responsible for their patients.:angryfire:angryfire

I discuss things my students bring to me, and if it is important to the patient care in any way, I direct them to approach their staff nurse and coach them in how to present the problem, also how urgently they need to track down the nurse or if it can wait.

Rocking the boat this close to graduation may not be in your best interest though, but definitely after graduation your dean should be informed. Don't know about the politics at your school, but do think of that. sigh. that it should even need to be said is sad.

[squirtle]

What an awful day! I am so sorry that you had to go through that. I don't understand the way your instructor acted at all. In our clinicals, they are always stressing how important it is to be a patient advocate, etc. You DID look out for this patient's best interest in more than one way. For example, you kept trying to explain to them that she could not handle her PO meds. If your instructor is going to stick you with a patient load and forbid you from having help then she needs to respect your assessment and evaluation of what your patient's needs are! The other thing is that nursing is team work. Don't they teach us that? In clinicals we are always willing to help out our classmates and I hear that in our last term we are taught how to delegate effectively as well. I know that in the real world there are bad days and times when you may not be able to have as much help as you would like to... I just don't understand what your professor was trying to teach you

[suanna]

Thank you and YES it would be ( and is) within the RN's power to call the Dr and request all the meds be changed to other routes. Our instructor won't allow us to actually *talk* to the RN in charge of our patient other than giving report, etc...so everything we ask for/do is done through her. QUOTE]

I'm glad this isnt the policy at the hospital I work or no patient would ever see a student. As an RN I am responsible for the welfare of my patients. If a student wishes to learn by participating in thier care I will delegate as much responsibility for that care as I feel they can handle safely-including all the care, but under my supervision. Your instructor is a idiot not to use the skills of the staff nurses to augment her instruction. Many staff RNs enjoy teaching and appriciate the added hands with patient care- thus the trade off "you help me with patient care and I will help you learn to be a nurse" I can't imagine abdicating the entire patient responsibility to a student if they were one of my assigned patients.

I think the most valuable thing you have learned this term is- DON'T TAKE A JOB AT THIS HOSPITAL!!!

[emmycRN]

It sounds like you did a great job!! And your attitude is wonderful as well.

Your instructor and the other nurses should have NEVER told you to force fluids with this patient. That places the patient at great risk for aspiration pneumonia.

If I were you-I would report this instructor!!

[SarasotaRN2b]

(((((Boonersmom)))))), I hadn't read the other posts yet, but I wanted to send across this hug. That pt was definitely 1:1. I think that you are going to be a wonderful nurse because you actually advocated for your patient even if you didn't receive the appropriate responses. Your CI has surely let you down...I mean, she is there to teach and help you...her response was totally inappropriate, and her criticizing you shows poorly on her, not you. While I understand your wanting to cry as it sounds like you had a real hard day, you did NOTHING wrong.

Kris

[marilynmom, LPN, NP]

Actually you did a fantastic job! You *knew* what to do and what should have been done, but as a student your clinical instructor failed to let you do what needed to be done for this patient.

I'm sorry you had such a crappy time, at least you know where you don't want to work Graduation is close, just use this bad experience as something to learn from I guess.