Posts Tagged ‘clinicals’

Wow, I can’t believe it. I posted my clinical hours fron the last 2 weeks, and I get a response from my instructor:

You are officially done.

Really? Already? Have I really put in over 660 hours of clinical time? I am conflicted about this. Part of me says, “You don’t know shit” and another part of me says “Wow, cool, I have learned a lot. ”

I think I will stick with the second part, I did learn a lot.

It’s funny, when I  just looked back at what I wrote, the negative feeling was in the third person, and the positive in first. Goes to show that I really do believe in myself and a little voice by my ear is telling me the bad stuff. My heart knows the amazing amount of knowledge I have gained, and experience.

There must be a point in this observation. Don’t listen to that little voice in your ear, listen to the one inside.

 One interesting thing, I got to meet a real live alligator wrestler on my last day, he had a bad shoulder. Why am I not surprised? He did tell us that alligators were easier to wrestle when they weren’t hungry…


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A few days ago a patient came in upset about her arm after being in the hospital for a couple of days. She is a lovely older woman I had seen a couple of times before, so when the nurse told me the patient’s arm was swollen, and “fibers” were coming out of the area that the IV had been, I was worried. I tapped on the door and went into the exam room. She was sitting in the chair with an anxious look on her face, holding her left arm out stiffly.

When I looked at the arm, I didn’t see any swelling or bruising, no redness, nothing. She pointed to her forearm and said “Look, see this dark area, there are fibers coming out of it! What is wrong, what could do that?” She was visibly upset. I looked where she was pointing and saw the distinctive square outline of tape marked in leftover adhesive. Little bits of thread and lint were stuck on it. ….Oh.

I explained to her what she was seeing. “Do you mean that all that is, is DIRT? I am so embarrassed, my husband will laugh at me!” After cleaning off the adhesive with an alcohol prep pad, I suggested that she could tell her husband she had a bad case of adhesodermatitis, but we were able to treat it successfully. She liked that and left with a smile.

So, the first two parts of the project are done: the matrix and the evaluative summary (review of literature). The entire floor of my study room and all available horizontal surfaces are covered in articles and studies duly printed on my printer after a “literature search” on all of those lovely databases. Most were rejected, 20 remained and were loaded into the matrix. Did any of you see that movie? I felt like one of those people in the little pods by the time I was done. My entire world had shrunk to the size of my laptop screen, the actual reality world disappeared. My husband forgot what I looked like and my dogs gave up on presenting enticing toys for me to play with.

The end result of all that study? I found out that the available research about diabetic foot ulcers and preventive education basically sucks. I barely managed to get enough info to do the project. Hope I still get a decent grade.

Actually,  I lied about the dogs not giving me toys. One of them thought I might be tempted with a mouse. Here I am, in crisp white lab-coat, ready to go out the door to clinical and…..

Yikes! But he was sooooo proud of himself!

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One thing I have learned is that the presenting complaint is never what you think it is.

Foot pain: An elderly lady came in complaining of foot pain. She had told the nurse it was bothering her a lot and wanted to know what to do about it. On examination there appreared to be a crusty area between the last two toes of one of her feet. She points out “It was pretty swollen up for a while”. I try to gently clean away some of the crusty stuff and just see a little bit of a macerated area. I questioned her if she had a podiatrist as she was diabetic and she said she did.

 “He operated on that toe a while back, and the nurse came and dressed it and they took out the stitches last week”. Okay……..Well, I advised her if it was still sore she should check with the podiatrist. She agreed that was a good idea, she denied any other issues when I asked if there was anything else she wanted to talk about.

I left to give my report to my preceptor, the good doctor….he agreed the patient should return to the podiatrist to have it checked.

We go back in the room. “So,” he says, ” I hear you are having some trouble with your foot, but that you are going to get the podiatrist who operated on it to check it out.”

“That’s right”, she says, “But that’s not why I came in today, I wanted to talk about my cough.”

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This week I get a site visit from one of the university instructors. The site visit is THE thing I am nervous about…very nervous.

Generally, I can go into the exam room now and get the patient’s history and complaint, do a physical exam to find the actual problems and report to my preceptor what I found, what I think the diagnosis is, and formulate a treatment plan. I can do all this and look reasonably competent and confident.

However, I have this thing about being watched and scrutinized while performing, my version of stage fright. This may seem strange after teaching nursing to LPN students, standing up in front of the class and lecturing and such. But being watched by someone who is scrutinizing my every move and checking items off a fifty point checklist…well, THAT is my bugaboo. The problem is, that when I am nervous, my mouth goes into overdrive, I start to talk really fast, I get tense and jittery.

Did you ever hear the term “blithering idiot”? That about describes it.

My family and friends, my preceptor, everybody says “you will do fine, you know what you are doing, don’t worry about it.” But it is not so easy. The words I gave my students when they went to clinicals for the first time are back to haunt me again. I told them to “pretend you are confident, play the part of a great nurse, the patient will never  know, and you will feel and act more confident”. Okay, I will pretend she isn’t there watching, I will pretend I am super confident. I will not degenerate into a blithering idiot. I will review the checklist a million times so I don’t miss anything.

I will try to forget that if I don’t pass this site visit and evaluation, I fail the class. O crap. I am confident, I am a great nurse practitioner, she isn’t there watching me, I will do fine.

Thursday is the day. Friday I will report back whether this blog continues or not.

I will be confident, I will be confident, I will do fine. I will do fine.

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Before I write my post, I have to express my sadness at the horrors that the people of Japan are facing. My prayers go out to them. No other words would be adequate…

Okay, my post about student nutrition. Every day I dutifully educate and counsel patients on diet and exercise to reduce weight, cholesterol levels and blood sugar. I feel like such a hypocrite.

 When the long clinical day is over, and I flop down on the sofa, the last thing I feel like doing is planning and cooking a nutritious meal, or riding my bicycle. I still have to spend at least an hour or so inputting the patient encounters into my log on the computer, respond to the weekly case study and look up and review some of the things I saw that day. By the time that is done, the brain and body are catatonic. My husband is not in any better shape. While he was unemployed for quite a long while, he was an angel, taking over the cooking and shopping. Now that he has a job, he is exhausted when he gets home. The job he has is very physical, and being in his late 50’s, it is tough on him.

Bottom line, at dinner time, we look at each other blankly, wishing that a cook would miraculously appear to feed us. So, in general this is the nursing student dinner hit parade:

  • Pizza: the guy at the local pizza shop recognizes Randy’s voice now and can take our order before we even say what we want. It is always the same, thinking up new and exciting pizza combinations is beyond our mental capacities. I suspect our house is programmed into the delivery guy’s GPS as a favorite.
  • Chinese food: again, the guy recognizes us, and also knows our order by heart
  • Omelet: It takes exactly 7.5 minutes to make an omelet with cheese and toast
  • Grilled cheese and soup: This takes about 13 minutes, so we need to be more ambitious for this one.
  • Healthy Choice or Kashi box dinners: These come in when we are feeling guilty about too much crap food and the clothes aren’t fitting so well.  One or two nights of this has us back on the phone ordering pizza.
  • Fast food: I can say we are proud of ourselves in that we almost never eat fast food, partly because it is so disgustingly bad for us and partly because we have to drive pretty far to get it.
  • Publix hoagie: If I have even a tiny bit of energy on the way home, I will sometimes stop and pick up a large Italian hoagie which we share.
  • Rotisserie chicken and macaroni and cheese: otherwise known as death by cholesterol and salt. Now this is not the boxed macaroni and cheese, that is WAY too much trouble, I mean the dish of nice, creamy frozen mac that you heat up in the oven. We can make this combo last a couple of days. If we are really ambitious, there will be a salad with this.

Here is hoping that we survive the nutritional deficits until I graduate. Then, I will have the time and energy to enjoy cooking again. My cookbooks and cooking magazines will get dusted off, and the kitchen will smell of baking and spices again. I will have to see if I can locate my bicycle under all the stuff in the garage.

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So, there I was last Sunday evening, watching TV and looking forward to my first full week of clinicals at my new clinical site, my own doctor’s private family practice. I felt a little tired, and had a slight sore throat. Nothing out of the ordinary, really.

Two hours later, everything was different. I woke up sweating, with a very sore throat, and nose all congested. I started coughing. By the morning, my temperature was 101, I had body aches, chills, terrible headache, was coughing very hard, and just generally miserable. Okay, I thought, I  have a nasty cold. Fluids, rest, vitamin C and cough syrup ought to do me. I’ll be right as rain in  a day or two. The next morning I thought I was doing good, temperature down to 99, things on the mend. Not so fast…

The train hit me early afternoon, temp shot up to 103, I felt awful, coughing my lungs out. My throat hurt so bad from all the coughing, it felt like I was tearing it out. Every part of me ached, including my head. Migraines are nothing compared to this, what with coughing like that. I thought my head was going to explode. Quick call to the doctor’s office, Tamiflu called in to the pharmacy. Holy cow that stuff is expensive! Okay, time to realize, this is not going to be over so quick. The crappiest part of all this is, I had my flu shot this year, and this still happened.

What followed was days of hacking, continuous coughing, to the point of throwing up, no appetite, no energy, just totally miserable. I lay in bed with a cold washcloth clamped to my head, tissues, a trash bag, thermometer, cough syrup and stuff to drink all at hand. The temp came down to 100 and stayed that way for two days, then dropped to 99 for two more. Finally, this morning: a normal temp. I feel completely washed out, and I am SO TIRED of coughing. At least the throat doesn’t hurt anymore, but the term “stress incontinence” now has a real personal meaning.  Of course, being a nurse, I listened to my own lungs (it’s hard to do that, I tell you, the tubing is not quite long enough on the stethoscope to do it easily) to make sure I wasn’t getting crackles or rhonchi.

Today, is the first day with a normal temp, I feel much better, just very tired, and I still haven’t gotten rid of the cough. My doctor, it turns out also went home on Tamiflu. I hope we are both recovered enough Monday that we can get back to clinicals and normalcy.

Having the flu sucks, it is like losing a week of your life.

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I am at the half-way point of my Adult Practicum term. The midterm exam is due this week, I’ll take it on Wednesday. Friday will be my first day of clinicals at my doctor’s practice for the second half of Adult Practicum. It should interesting. My greatest complaint about my previous two preceptors is that they didn’t tell me enough.W hen I saw my doctor last week, he said he has been accused  of telling people how to build the watch when asked what time it was. That works for me!

Seeing the patients that came to the health department for their primary care was definitely “interesting”. Coming from a background with high work ethic and a belief in the value of your health and the need to do everything to maintain it, mostly to be able to keep the ability to work and be productive, it was a shock to see what was considered  important by some of the patients I saw. Their values differed from mine in several major respects.

  • For them: 1) if Medicaid pays for it, I want it. If it isn’t paid for, I don’t. 2) If it doesn’t make me uncomfortable, it isn’t important. 3) Whatever I can use to go on disability is good, even if I am a big, strong, young man and my only disability is a bum knee from basketball. 4) Why bother with prevention if you can just fix things afterwards.
  • In my world it goes 1) I will find a way to pay for it as healthcare is important 2) What ever it takes to prevent future problems or treat current ones gets done, I need to keep healthy and active so I can work and do what needs  done. 3) Disability is the last thing I would ever want, I will find a way to work and stay independent until the last possible second (so bad that I can’t get out of bed, well, even then you can use a phone or computer) 4) An ounce of prevention is worth a pound of cure.

A woman came in whose main complaint was a sore in her armpit. When the nurse took her blood pressure, it was 210/102, approaching stroke city…then the patient admitted to having some pain in her chest. “But that is not why I came in, I want you to deal with the sore under my arm!” All through the ECG she complained about the armpit thing. Thank goodness there wasn’t an ischemic event going on (heart attack), though the ECG showed LVH (enlarged heart, probably related to the ridiculously high BP).

We reviewed her BP meds, changed the doses a bit to better address the BP issue, tried to educate her a bit on the risks of heart attack and stroke, etc. Not interested, “Just take care of that thing in my armpit!”. Okay, we drained the small abscess that had formed  from a folliculitis related to shaving her armpits. Then she was happy.

I have to wonder if a large part of the higher rates of stroke, heart disease, diabetes, uncontrolled hypertension, etc. in the “underprivileged” is a result of noncompliance with treatment plans, or simply not caring enough to take care of their own health. The care is there and available, but if you don’t use the care available or follow the treatment plan, you will not be healthy or get better.

I have seen several patients with genital warts, lots of genital warts and big ones. Personally, one teensy little bump would send me straight to the doctor’s office in a screaming panic (not that I would put myself in the position of it being possible to get such a disease if I had anything to do with it). I can not conceive of letting things go the way some of these patients did. When the treatment is finished (which is painful, as it basically consists of burning them off with acid) I sit and chat with them a bit, educating them on prevention, etc. Not a single one of them used condoms. They knew about condoms, they knew about safe sex, but it didn’t seem important to them. I asked some of them “So, you want to be a daddy?” The answer of course was usually “no”, or “not now”. I asked if the girl they were having sex with was the one they wanted to be the mother of their children. The answer to that was always “no”. They know that sex=possibility of babies, but when it comes to their own personal selves, “I wasn’t thinking about that.”  The universal attitude seems to be: fix it if it happens when it comes to diseases, and for some of the girls Plan B or abortion as contraception. Thank goodness, there are a lot of girls that take advantage of the free contraception offered by the health department.

The concept of being responsible for the results of your own actions doesn’t seem to be a big value these days. Or as the young people say: “Whatever.”

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