Clinical Day 1: Discoveries

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A lesson learned few years ago, but never forgotten.

“No, hon, you’re not going to want that. Those are old. You’re going to want these,” said the nurse, pointing at a rack full of thick binders on the side of the desk.
Bewildered, I put the first binder back on the shelf (it was big and heavy) and turned to face the other rack.
Not really sure what I was looking at but attempting to look professional, I grabbed the binder with my newly acquired client’s room number on the spine, clutched it to my chest, and practically ran from the nurses’ station.
As I fled back to the safety of the visitor’s room that the freshmen nursing students had confiscated for headquarter purposes, I could imagine that poor nurse’s thoughts in the back of my mind. “That freshmen nursing student, thinks that she’ll be an RN someday and she doesn’t even know what a chart looks like!” I could just see her shaking her head and rolling her eyes at the inconvenience of having to deal with a floor full of freshmen. I made it back to the visitor room and sank into a chair with the chart in my lap.

My need to stay in my comfort zone was very quickly overcome by my clinical instructor’s orders to “Find your client’s medications from the chart and write them down.” Then she added with a touch of sadistic delight, “Some of these clients are going to have a lot of meds. One student last year had a client with twenty medications.”
Staring at my instructor with disbelief coupled with shock, I tentatively opened my patient’s chart. Pages and pages of information jumped in front of my eyes. Words that I had never seen before, much less understood, attacked me from the pages. I had no idea where to even begin looking for my client’s medication information.
Suddenly remembering that I would need more care plan information about my client than just medication info, I was struck with the bright idea of taking my client’s chart into her room and sitting with her while I attempted to decipher this terrifying binder. At least I wouldn’t be under the eyes of some of the more experienced freshmen or my clinical instructor. I was still delusional enough to think that my classmates were less confused than I was. If I had actually looked around I think that I would have seen the same deer –in-the-headlights-look on their faces that was so evident on my face.
Quickly sucking in my breath like a diver ready to jump, I rose from my chair, slammed the binder shut, and started walking briskly to my client’s room. As I left the visitor’s room I suddenly felt a surge of confidence. After all, here I was, in my new uniform, young, full of ambition and I had almost four weeks of classrooms lectures and lab time behind me! My self-confidence was returning! I felt knowledgeable, smart, and self-sufficient.

Then I passed the nurses’ station where I had gotten my chart. My confidence quickly dwindled as I walked, no; I sneaked, past that station. No snappy uniform or college based confidence could stand in the face of plain old experience that was represented by those sitting behind that desk. I quivered.

Still clutching my binder, I made it past the nurses’ station and arrived safely, albeit somewhat un-confidently, at my client’s door.
I then gave myself my one thousandth pep talk of the morning. “You’re doing fine, everyone feels like this on their first day. Just relax.”
We had been taught to always knock before entering a client’s room, however, upon meeting my client earlier in the day I had discovered that in my client’s instance that little textbook jewel could be thrown right out the proverbial window. I would have to hit that door multiple times with a crowbar before my client would even hear it. The dear woman’s hearing was not very good, and so, I concluded that all textbook information could be adapted to meet specific client needs. Looking around me, half expecting, half afraid to see my clinical instructor behind me, I discarded textbook policy, and walked right in. I walked up to my client, being careful to approach her from the front so that she could see me clearly. Leaning towards her, I raised my voice ever so slightly. “Hello, Ms. So and So! My name is—— and I am a student nurse. I am going to take care of you today!”
That was my very first ever clinical experience. I wrote about this experience very shortly after it happened. I have learned so much since that day; it would take me thousands and thousands of words to even begin to scratch the surface of all that I have learned since that first clinical day.

First of all, I learned that I was not alone in my feelings of nervousness.

I learned that I was not the only freshmen nursing student in the world to have felt so illiterate at the clinical setting.

I learned that my instructors were and are not sadistic, but in fact want to push me to my limits and challenge me with new experiences.

I learned that my instructors were approachable when I was unsure of myself.

I learned that my instructors didn’t mind me ‘adapting’ textbook policy (within reason of course!)

I learned that it was possible to understand a client’s chart!

I learned that the clinical staff can be invaluable tools for learning.

I learned that if I didn’t know anything, I should ask questions.
And the most important thing I learned that day was how to apply my textbook and lecture knowledge. I learned that no matter how much I learned in school, or how much I knew, when it came down to the client, it had to be personally applied to that client.
Although in the school lab, I would lose points during a re-demo for forgetting to knock on a client’s door, in the “real world”, if my client couldn’t hear me, I had to find another way of making my presence known respectfully without knocking on the door. I had to adapt my knowledge to meet a specific situation.
That little lesson turned the ‘light bulb’ on for me, and helped me to understand the nursing process.  It helped me to understand how to critically think a situation, even in a very small way.

I think that I learned more in that one tiny experience, with a hard of hearing lady in a nursing home, than in four hours of lecture on critical thinking. And, small as it was, I know that I will remember what I learned on that first clinical day for the rest of my life.
~SarahLee,RN

Please-Just Let Me Go Home Part II

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~Continued~

When I called the Dr.-he again prescribed an even higher dose of the same medication. I gave it, hoping that this time, it would be enough.

My shift was almost over, and as I was giving report to the oncoming nurse, Virginia was again trying to climb out of bed. Together, we both put her in a chair and brought her to the nurses’ station, attempting to calm her down as well as put her in a safe area where they could keep an eye on her throughout the night.

She was getting increasingly more agitated, and kept saying “Why is this happening? Why can’t I go home?”

I left feeling devastated that she had to be in such an emotional state.

The next day I heard what had happened after I left for the night.

Virginia did not get better. She continued to get more and more agitated throughout the night.  Even ANOTHER dose of the medication was given to her without any results whatsoever.

Finally, sometime before morning, one of the nurses was going through Virginia’ chart and realized that a medication she had been on at home had not been prescribed to her. A medication that a person could experience withdrawal from.

Surprised at finding this, the nurse notified the physician, who ordered the medication.

And by around noon the next day, Virginia was completely back to her normal mental state.

And she told me later that the night before had been “The worst night of her life, and she had lived a nightmare.”

I tell this story because I think of how I assumed. I assumed that Virginia, because she was elderly, was demented. How that once the night was over with some medication, she would be fine. That she was ‘sun downing’ and probably just had some ‘memory issues.’

I assumed that how I have treated dementia patients in the past was how I could treat Virginia.

When in fact, she did not have dementia at all, but was suffering from medication withdrawal!

Just because someone is elderly does not mean that they must or will be confused.

Just because one medication works in one situation, does not always mean it will work in another.

When giving care, never assume.

You could change a person’s life for the better.

Or for the worse.

You never know.

 

 

 

 

 

Yes, That Happened to Me

 

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While working on part II of Please-Just Let me Go Home I thought that I do something that I have never done before.

I want to ask my readers a few questions.

Have you ever been a patient in the hospital? A visitor?

What are some of your best and worst hospital experiences?

Working in healthcare is a daily learning experience. We encounter people who are often scared, sick and vulnerable at the same time.

What did someone do for you that was wonderful? That was awful? How did someone approach you that you appreciated? That you didn’t appreciate?

Leave a comment and share your story!

Please- Just Let Me Go Home

 

 

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She sat in her chair by her bed and talked to me about her life. She was busy, her house was a mess, and she didn’t know if she would be well enough to make Thanksgiving dinner for her family next week. This was her second night here at the hospital “Just because I fell” and she wanted to be home. She was “Sure my heart is fine, they haven’t found anything by now anyway.”

As I took her vital signs I encouraged her to eat her dinner and to “Worry about you. You can’t worry about what you are going to do until you feel better.”

She smiled and relaxed a little at the reminder. She started to eat her dinner and I continued on my rounds.

As I start my shift by assessing my patients, when I go in and out of rooms I continue to engage in ‘small talk.’ By this I let my patients know that I care, that I want to talk to them, they can talk to me and it also gives me a chance to assess their cognitive abilities.

As I left Virginia’s room I was encouraged to have met an elderly (80 something year old) woman without any evidence of confusion or an altered mental state.

The evening continued on and suddenly, around eight-o-clock, Virginia began to seem a bit more confused. She began to insist (kindly but firmly) that she was going home tonight, that her husband would be back to get her. Attempts by me to remind her of our conversation earlier that she would at least be staying in the hospital one more night did no good. She was very insistent but at times re-directable.

Several times over the next few hours we would find Virginia almost out of bed. She needed the help of a walker normally, although she could move quite well all things considered.

We had to put a call bell on her bed that alarmed every time she tried to get out.

She was getting angry, and trying to hit the staff.

She also seemed to have developed a bit of a body tic that could be noticed when she was laying in bed.

When the confusion began to get past the directable stage and I started to notice the tic I gave the Dr. a call and asked him to come out and look at her.

He very nicely arrived and came into assess Virginia. We both were aware that Virgina did partake of an alcoholic drink in the evenings. It was assumed that perhaps she partook of a bit more than she had revealed. The idea of ‘sun downing’ was also discussed and so he prescribed a small dose of IV Ativan.

The Ativan didn’t work. It didn’t seem to change anything and so I called the Dr. again.

He prescribed another dose of Ativan, again small.

I gave it, and it did nothing. Virginia was still climbing out of bed, her alarm kept going off, and she was insisting very strongly that she “Had to go home and where is my husband?

The problem was, however, that after the Ativan, Virginia was not only staying confused, she was also getting weaker and more unsteady on her feet.

By now it was ten at night and I was getting more and more worried that Virginia was going to fall and break a hip because she was getting more and more confused, agitated and now had strong medication in her system.

I had seen this scenario play out many times with dementia patients.

At one point I was two rooms down from Virginia administering medications. I heard her alarm going off and ran quickly to her room, only to find her already to the door, holding onto the door frame tightly because she was so unsteady.

She looked at me with a glazed and confused look and said “Please, I can’t stay here tonight, I have going home! I need to leave, I’m so sorry, why do I feel this way?”

And I looked at her and wanted to cry, because she could not process why she was here, needed to be here and could not go home. And I didn’t want to give her any more medications, but what could I do? She was too unsteady to walk, too agitated to stay in bed and too mentally distressed to relax.

So I helped her back in bed, persuaded her to stay there for about two minutes, and went back to nurses’ station to call the Dr. yet again.

~To be continued~