Critical thinking nurse example: CTNE: Levophed should be started in an IV line such as a CENTRAL LINE preferably, or at the AC or higher. If you’re pulling blood away from the extremities then you don’t want levophed running in a persons hand.
15 Essential things to know before Clinicals, > IF < you want to be liked.
If you are a nursing student, I urge you to tear out this chapter and duct tape these hints to your forehead. Unless you want to be hated in clinicals. Your move. Definitely post it on Instagram if you walk around with these duct taped to your forehead. Below you will find 15 important guidelines that will make you successful in clinicals. My Student Nurse Helpful Hints (SNHH) are raw, and un-apologetically yours:
Student Nurse Helpful Hint #1
SNHH #1. When a nurse is charting during clinicals she is not silent because shes dying for you to interview her. She is CHARTING. Next time you’re writing your ethics paper that’s due in 20 minutes I want to break through your room and start asking you every question under the sun about why you chose nursing and what events in your life led you up to this point and then have you be happy to answer me. The nurse is already backed up enough teaching you their daily auto-pilot tasks and breaking them down to you kindergarten style, which trust me, is a HUGE time delay. It’s great your interested, and those are sometimes the best questions to open up communication with your nurse to build rapport. Especially when your future job could be dependent on a certain nurse knowing a certain manager, that knows a person, that knows a person, that knows a person, etc., to get you your dream nursing job. Just PLEASE ask when there is a more appropriate time. Charting is not one of them.
I can’t tell you how many times this happens to me during my shifts on a daily basis. For some reason God has graced me with the skill of talking to anyone, and anything that moves. When I am chest deep swimming in things to chart on my patients, it is always when the janitor, police officer, pharmacist, etc., always appears to see this as a prime opportunity of “Jenn, the wilder-beast, sitting still in her natural habitat looking for conversation” and asks me 20,000 questions. As great as it is to talk and have a social life beyond being co-workers, it is extremely difficult to concentrate on your charting and have a conversation. So difficult that it’s usually the conversation that get’s done and the charting is delayed. Politely, I like to tell people, “Hold on, I’ll answer you in a second, but I need to finish typing XYZ.” Or, “Oh mi gosh! Great to see you but you have to give me a minute because I need to chart XYZ.” Usually I am always pleased to see someone, but sometimes the chaos doesn’t stop, and you can’t either. #NurseLife
Student Nurse Helpful Hint #2
SNHH #2. I told you earlier, and I will keep telling you: If a nurse teaches you something and you’ve already done it 20 times over, appease the nurse and smile, nod, and say thank you. The nurse does not HAVE to explain anything to you. She has no idea if you have ever done anything before, nor does she care, and you are there to learn. So be the freaaaaaking sponge. As rudely as this may sound, when a nurse has never met you and is interested in showing you something the way she does something, you should duct tape your mouth shut and watch. Sure you may tell her that you’ve done a procedure before, but always appear interested in the nurses way of intervening. RN is behind their name for a reason, and not yours. Most likely the RN has done this billions of times and may show you something new. This will do WONDERS for your like-ability in clinicals. I know a lot of you may have prior experience, and you may have done something before due to your prior profession. Maybe, you might even have done more IV’s than the nurse teaching you or know more about a subject than the nurse knows (I know, it’s scary, but can be true); but take this advice for exactly what the underlining meaning is. Leave your ego of “how advanced” you are in the classroom. Actually don’t even bring that to the classroom because it annoys your classmates. Leave the ego in your bedroom under your dirty under-wares. You may want to impress your preceptors, or show your nurse preceptor that you are advanced, but knowing how to do this is key. Being the advanced student can give you the “edge” into getting the new-grad position you want. But, there are many ways to do this while being respectful, and humble. Ask questions, show her that you understand pathology, take on responsibility or ask for it. ALWAYS do it with RESPECT. No one likes a know-it-all or a one-upper. I promise you, this helpful hint is one of the most important to your success in clinicals.
Student Nurse Helpful Hint #3
SNHH #3. You are never better then another co-worker, colleague, or classmate. In clinicals you are exposed to the hundreds of roles people play in a hospital facility and become aware of your role as a student nurse. Some hospitals have Environmental Services workers that are responsible for cleaning all patient rooms, and some hospitals the nurse is the Environmental Service worker once a patient discharges. Your Unit EMT Tech’s are your second-hand man to delegate tasks to assist you when you are overloaded with nursing tasks. Did you see what I did there? The EMT Tech is NOT there to be used and abused so you can text your friends your weekend plans or Tinder. Your EMT Tech is there to HELP you when you are overloaded with NURSING tasks. HOWEVER, when you are the student nurse, you are expected to perform the roles of an EMT Tech. EKG’s, sometimes IV’s per facility, bed changing, cleaning, wiping butts, changing clothes, walking Betty the 96 year old to the toilet or giving her a bedpan. And once you have RN after your name, you are STILL fully capable of cleaning up Tom’s bowel movements, just as much as the environmental services guy is capable of wiping down a trauma room. Never have the attitude that you are a pay grade above it. In fact, you most likely clean up more feces, vomit, and blood than some environmental services workers do in a day, so remember you are no better. And that lady that serves you coffee, she most likely has a story as well and deserves your respect just as much as you’d like it from the doctor. You. are. NEVER. better. than. anyone. The volunteer that transports patients might have been there 25 years and has daughters, sisters, brothers, cousins in high places. You. Are. Never. Better. A friendly hello goes a long way, even if someone does not appear ‘hello’ approachable. When you offer the hello first, you make that person appear to be the un-friendly one. But not you. You are the happy one that is grateful for the learning opportunity that is going to help you be good at your career, and who you are becoming. And when you are good at your career, you learn to float through your shift and you become closer to SupeRNurse. Do you think the miserable student nurse is going to get picked to see and do the “cool stuff” in clinicals? Or the one with a smile on their face and ready to learn!? Your attitude and willingness to learn when you show up to clinicals is what will determine the success of your time in clinicals. We notice who is there to work, and who is there because they have to be. Nurses see it, doctors see it, and patients will see that difference from miles away.
Student Nurse Helpful Hint #4
SNHH #4. Take advantage of your ignorance. Faster than you know it, you will no longer have a hand to hold. So squeeze that lemon for all the juice it’s got. Watch a surgery or pass an oral med? Go to the damn surgery or make yourself in the know or available to go see interesting things. You will not get these opportunities when you have a full patient load and you might learn what you thought you liked, (being an OR nurse, L&D, NICU, etc.) isn’t what you thought it was. I can’t tell you how many times in my clinical rotations I was so fortunate to be able to “scrub-in” or pick up a patient from the helipad and do things that I would never have the opportunity to do in a real nursing shift. My preceptor’s were always motivating me in school, “YES! Go do it! Go see it!” with some jealously behind their approval. Opportunities are sometimes difficult to come by because some doctors may not want anyone outside of the “need to be there” in the room. Some facilities are not teaching facilities and do not accommodate to teaching moments. I’ve always carried the outlook that the more things I am able to see and learn, the safer of a nurse I am for my patient. When you understand more, you are able to help explain things to lesson the anxiety to the patient. During my time in Colorado I was able to go see the Hyperbaric pressurized chambers and learned about the process of oxygenation and delivery. Now if a patient needs Hyperbaric Oxygenation Therapy (HBOT) for something such as carbon monoxide poisoning, I am able to answer questions and help ease that patients anxiety on the process. You can never be too educated. For me to go to the Hyperbaric chamber and have a doctor give me an educational session required another nurse to cover my patient load. So you can imagine that learning opportunities off of your unit while on the clock are not easy to come by.
**Educational tip: Hyperbaric Medicine is used for numerous clinical conditions. Using 100 percent oxygenation delivery and highly monitored care, the doctor is able to provide results sometimes with 1 to 2 sessions or 40-50 sessions depending on the condition. The time frame of being in the chamber also ranges from minutes to hours. Hyperbaric medicine has proved to be highly resourceful for injured or damaged tissues, wound healing, blood vessel formations, infection control, carbon monoxide poisoning, or gas bubbles that cause tissue obstruction.
Student Nurse Helpful Hint #5
SNHH #5. It’s a scary world when you don’t have anyone double checking your work. Example: The new nurse that pushed an ‘IM only’ drug in an IV and caused necrosis to an oncology patients arm. Fun fact. Phenergen is a commonly used anti-medic when Zofran (another antimedic or anti-nausea) isn’t enough to stop someone from throwing up or feeling nauseated. Phenergen if pushed through an ARTERIAL peripheral line could result in someone losing their extremity. Of course no nurse tries to put their IV in an artery, but it CAN happen. If you aren’t 100% sure its a venous line, you can run into trouble.
Now that I’ve scared you and you may need to put this book down and go change your underwears, you can fully understand the importance of this helpful hint. When the boards are passed you are now expected to be ready to delegate and implement A LOT of tasks quickly without making a mistake. Trust me when I tell you, you MUST put the ego aside and NEVER take the lazy route. Ask a reliable or veteran nurse co-worker, look it up, or both. And if you decide to not look it up, and take the advice from a colleague then you better make sure it is right because harm to the patient is still YOUR nursing license and responsibility. Your mistakes are not a glitch in the computer system. Your mistakes are a human beings life! Imagine if it was you in the patient bed. Or, it could be your cheek-pinching grandma one day! It is easy to take the lazy route, or shortcut interventions while your brain is full of mannnnnny tasks you still have left to do. When you are in one patients room you are no longer accessible to what is going on in your other patient rooms. The anxiety and worry of your other patients can be overwhelming and can distract you from the task at hand, resulting in distraction and errors. One of the best things you could do is stop and ask yourself if what you are doing to your patient is the kind of care that you would want YOUR nurse to be giving you if you were laying in that bed. Right now. I want you to say the following words I am about to write out loud. And if you’re in a public place and would look extremely awkward talking to yourself out loud, then whisper the following words… You ready? “Is this the kind of care I would want my nurse to give me?”. And repeat. “Is this the kind of care I would want my nurse to give me?”. Third time is a charm right? “Is this the kind of care I would want my nurse to give me?”. Now you have consciously told yourself to become present in the moment. Perform that sentence in your head while you are running around like a chicken with your head cut off and I PROMISE you, you will start to hone back in on what is most important.
Student Nurse Helpful Hint #6
SNHH #6. This may hurt a little bit, but, you will not be fully respected until you have shown that your dues are paid. Nurses don’t trust anyone. And I mean, EVERYONE. I once had an anesthesiologist come down to the ER to take my patient to surgery and channeled off my drip because the IV machine was beeping. As I walked in and caught him in the act, I politely acknowledged to the anesthetist that he had just turned off LEVOPHED (nori-epiphrine). If you are on a levophed drip, you are circling the drain at the bottom of the toilet and the handle is half pushed down. Your fatality is in grave danger. So as a student nurse, for a nurse to TRUST YOU with something or leave you to your own, you should take that as a great sign of respect. When it appears that a nurse is over-bearing or “watching you like a hawk”, think of this example and remember that at the end of the day, that person’s life is fully in THAT nurse’s hands. Don’t take it personal. It would be doing yourself a disservice to think the nurse thinks YOUR not competent. The nurse thinks EVERYONE is a threat that isn’t the primary role player to the patients life beyond the doctor without themselves in the room. That is why we are nurses. Sometimes during my shift I feel like I am Katniss in the hunger games and at any given time my poor Peta (the patient) could be under attack and can’t take care of himself. If you don’t feel like this over your patients then I urge you to take a look at other professions.
Educational tip: Levophed or Norepi-phrine is a Catecholamine used for low blood pressure and heart failure. It’s job is to pull your circulation away from the extremities and into the core of your body where your important organs are such as your heart to increase your blood pressure. Levophed is a last resort advanced critical life support (ACLS) drug.
Student Nurse Helpful Hint #7
SNHH #7. Giving patients a sponge bath is another way to earn your right before the “cool shit.” Most nursing programs today will always start your clinicals at a geriatric facility. Working with the elderly is a great way to learn how to maneuver body mechanics, not be afraid to touch patients, see some of the most gnarliest wounds you’ll ever see in your life, and become really good at code browns….. aka poopy pants; changing or putting on a brief.
Let me pump the brakes right there and jump up onto my soapbox. The term “brief” is preferred over “diaper” to maintain respect and dignity to your elderly patients. When I hear the word diaper being yelled out by my fellow nurse in front of an elderly patient my spine gets chills up it every time. Is it a diaper? Yes. What do you think of when you hear the word diaper? Usually diaper is associated with babies, potty-training, incontinence, and digressing from appropriate human functioning. Many elderly patients have a difficult time with depression and coping with their lack of independence. Almost a century of living, the elderly patient has walked this earth respected, hard-working traits, raising humans from day 1, and provided for their generations they are leaving behind. Slowly their age strips them away from rationale thinking and daily independence. Some of your patients may be triple your age. It can be embarrassing enough for some patients to pull their pants down and have a stranger wiping their behind and exposing their private parts they have spent their entire life hiding from random people. The term diaper is another way to affirm their loss of function. You don’t have to agree, but it is a way to show respect. You may never know what kind of depression someone is facing while aging is kicking in. We are all going to get there one day. And I now leave my soapbox.
During clinicals, and especially this first one, it is helpful to buddy up with someone to tackle on the nastiness together. Forever as a nurse, changing a patients briefs, linens, etc. is 100% more efficient with two people than one. Some CNA’s/EMT’s are Houdini’s and can make your two person linen change look like a tortoise race versus their own magical bed changing skills. So take notes, and show them you are not afraid to help them. As a nurse, your EMT’s/CNA’s will always be willing to help you when they see you aren’t afraid to get your gloves dirty as well. And my stars above….. when you see ANY employee touching things glove-less like a brief…. don’t follow by example. Disgusting. Just remember when you go to open up the door, they touched the same handle.
Student Nurse Helpful Hint #8
Student nurse helpful hint #8. Minor air bubbles in the primed IV line is NOT a big deal. Unless it’s greater than your pinky finger, or a bubble in a central line, or pediatric baby. When you master the art of priming an IV line without a million trillion bubbles you are allowed to do the happy dance. Just please stop standing there flicking the line like a real rookie over 0.25mL’s of air. Or you’ll just annoy me. #girlBye
Educational Tip: Priming the IV line is very simple. Stab the bag upside down. Continue to squeeze the fluid bag until air leaves the fluid bag and the fluid starts to fill the chamber half way. When you flip the bag right side up the fluids will start to instantly flow down the line, most likely bubble free due to all the air being pushed out. Close the clamp once beading (fluid drops) come out of the exit port.
Student Nurse Helpful Hint #9
SNHH #9. You will quickly learn how nurses can be creators of judgment. Judging pain, judging conditions, judging history, judging patients use of words explaining their symptoms. Judging is really how nurses get by on their shift. As negative as that sounds, I mean that oppositely. If you can judge the reality of patients situations/conditions and gage your priorities through objective and subjective data, you can make wise decisions through your shift. Doctors rely on nurses judgment when they are unsure of their path they want to take and they trust the particular nurses judgment. “What did you think of patient in room 10?” However, it is easy for nurses to get carried away with judgments and create their own witty or personal opinion into their judgment. I would be the world’s biggest liar if I stood here and said I haven’t had moments of voiced personal judgment among my peers. Most of the time these judgmental comments are nurse-stress-venting moments among each other. Yet, YOU as a student do not get brownie points among your fellow nurses for joining in on the ‘judgy-party’. So pretending you’re judging the patient along with the nurse will not get you anywhere. You have not had the experience of being a well-tuned nurse… YET, so you have not earned the right to be apart of the conversation. Take our jokes, laugh, and do not take them to heart. The judgments you hear in clinicals is actually what motivated me to write this book. Judgments do NO one any good. But at times, it is reallllllllllllllllly funny or has some truth among the lines. Much more on this later.
Student Nurse Helpful Hint #10
SNHH #10. If you are planning on having a patient load, or shadowing patients, you better show up to report with your coffee already (or half) in your belly, and a pen and paper in hand. As I’ve watched student after student “Show up” for clinicals, you can learn A LOT about who is motivated to play nurse and which student is not. If you are not listening to report, or trying to listen, do not expect the nurse to think you are interested in doing anything hands on that day either. YOU set the stage for your appearance of motivation, and if you do not appear motivated, then the nurse does not have to be motivated to help you learn either. Nurses aren’t there to hold your hand. Mic drop.
Student Nurse Helpful Hint #11
SNHH #11. Nursing is truly an art. It is tremendously interesting how everytime you shadow or meet a new nurse, you may find a more efficient or creative way to do a nursing task. As an experience RN, I can not tell you how many times I have learned from my nursing colleagues of any level of experience throughout my shift by accompanying them with a procedure, observing, or them showing me something new. As a travel nurse, I orient to a new hospital very frequently and usually my orientations are one shift. It never fails that the nurse orienting me does not know my skill set and will at times hover over me or teach me things as if I am a new grad. Does it bruise or bother my ego? No. Because I am confident in my skills and capabilities that once I am free, I am free so if someone would like to show me their way, heck why not take a lesson? What would showing them that I “already know” how to do something do beyond appear rude? I might just learn a new tip.
Moral of this tip: You do not look like an idiot by staying quiet and watching every nurse you’re with, or asking them to show you first. It is AMAZING how many ways there are to do just one small procedure, such as taping down an IV line, or sterile steps of a foley insertion. You do not need to prove that you already “know” how to do something because you really might learn a new way to do it, as I do every now and again.
Student Nurse Helpful Hint #12
SNHH #12. We understand how much you want to fit in and feel included in our shift. We understand because we have been there. And trust me, we also have had the nurse that “eat’s their young” and we’ve also have had the all-star nurse that taught us a billion things in one shift with patience and a smile on her face. You must always remember that you set the stage. If you show up to clinical alert, ready, happy, pleasant, and do not show the precepting nurse that you are smarter than she is then you most likely should have a good shift. Silence is not always a bad thing, as long as you also show initiative and ask questions. The nurse knows what it is like to be you, and the less ego you show the less ego that the teaching nurse should present to you too. And as an important lesson and to be very brutally honest; the nurse really does not care how much experience you have prior to meeting her or that you’ve done something 20,000 times over. I know I am getting repetitive, but I cannot stress this enough. The nurse that is teaching you knows she is there to teach you and show you a day in her life. Remember that. ALWAYS. Learn young grasshoppers, just learn.
Student Nurse Helpful Hint #13
SNHH #13. Never panic. You walk by a room and a patient is blue and not breathing. Everything in your body is going to tell you to panic. Rightfully so. But ask yourself right now what you would do if this was reality!? What are the first steps you would take? Before you read on, go ahead. Shut your eyes and think of what you would do if you stumbled upon someone in arrest. Congratulations you are now already one step closer to actually saving someone’s life and you weren’t even on shift. Preparation in our field is the number one thing you can do to save a person. In this case, I can tell you the best answer; call for help, check for a pulse, and if pulseless initiate compression’s and get someone on an ambu-bag for full resuscitation until the team shows up and more can be done, but sometimes when “oh shit” moments happen, we freeze. Every room you walk into you should look for an ambu-bag when you are feeling that moment of fear/doubt creep in. In the perfect world, you will always have an ambu-bag stocked in your room, but real life nursing is not always smooth.
Student Nurse Helpful Hint #14
SNHH #14. How am I going to remember everything?! Trust me, as you nurse-on, your senses will start to hone in on what is important to you without you actually needing to visually note it in your head. This will become a second-nature habit that you form over time. I guarantee you by the time you are done with your senior rotation, you will be able to sit at a desk and remember the side someone’s IV is on even if you haven’t touched it. When you aren’t in heightened-freak-out mode of clinicals, assessments, panic, fear, and “how do i do this” worrying; you will start to become highly observant without even trying. It will happen. I SWEAR.
Student Nurse Helpful Hint #15
SNHH #15. This is not grey’s anatomy. Patients will code. Patients will yell. Patients will violently scream, “NURSE! I NEED A NURSE!” just for a warm blanket. I am not joking. I can remember a patient had a rapid response called on them (which is a team that is called to respond to a patient appearing to be in distress or increasingly appearing to be close to coding/arrest) and someone turned to the new CNA to get the crash cart. The CNA brought the crash cart in, in the mean time knocked over a bedside table, broke a steel laundry cart, and ran over someone’s foot. This is a very, very, dramatic crash cart entrance. We cannot perform a code if we lose nurses to foot fractures. Panic will always arouse inside of you. Take a breathe, and slow down your anxiety. And if this is ever you, please, just tell people you are needing some clearance for the cart, and get someone to move items, or create your own space. Yell loudly and politely if you need to. Manners are never dead. Not even in a code, btw. :o)