appendix

A
Pointers for Students:
How to Look Like You Know
What Youre Doing
Clinical experiences can be overwhelming and confusing; the environment is filled with distractions. What you experience often doesnt resemble what you have read in the book! We want to
help you become a good clinician. The following are tips and tricks contributed by the writers
of these cases. They are presented in no particular order of importance. Dont read all of them at
once; read a few here and there, think about them, and apply them as you get the opportunity.

General Suggestions
There are 5 instruments every nursing student should carry at all times. Never lend these
items to anyone unless you can afford to replace them without complaint. These 5 essential
items are a good black-ink ballpoint pen; a high-quality stethoscope; a pocket penlight (preferably with pupil sizes or centimeter ruler on the side); a medium-sized hemostat (straight
Kelly); and a pair of bandage scissors.
Purchase a high-quality stethoscope. Try listening with several different types, and choose the
one that is best for you. Engrave your name on it. Your stethoscope is a very important
tool.
Staying hydrated will help you stay more alert. Drink plenty of fluids. (Besides the health
benefits, this gives you an excuse to go to the bathroom for 30-second breaks!)
Keep a quick snack handy. Sometimes you need a pick-me-up and dont have time for meals
or to leave the unit to get something.
Plan something special you can do to help alleviate stressand use it on a regular basis.
Avoid use of slang or words that could offend patients and families. Be aware of your patients
comfort level. Do not call patients by their first name unless they have given you
permission.
Assume nothing and take nothing for granted.
Listen and observe carefully. Be aware of changes and try to assess their significance.
Watch how the nurses you work with do things, and pick out things that work best for
you.
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You can also learn from a negative example. If nothing else, you learn how not to do
something!
Projecting confidence and a matter of fact manner will usually put the patient, and yourself,
at ease.
Take care to respect each patients confidentiality. Conduct interviews and examinations in
a private and professional manner.
Watch for physical or emotional scars. Health care touches on the most intimate experiences
of our lives. Individualsboth men and womenwho have been subjected to the degradation of sexual abuse and molestation may be especially prone to shame, aversion, or aggressive
reactions.
Dont be surprised when you discover that many adults are not knowledgeable about the
basics of elimination and sexual functioning. Their ignorance or discomfort often is covered
up with humor or aggressive behavior.
It is imperative to give patients written instructions and information. It is critical that patients
be able to understand the information and follow the instructions. Therefore, patient handouts
should be developed using fonts that are a bit bigger than average and easy to read, and the
text should be written at a sixth grade level of comprehension.
If you have a limited budget and a clinical setting of patients who speak more than one language, ask for volunteers to help translate educational materialand then have that work
double-checked. Local ethnic clubs or support groups can be a good source of translators.
Never trust equipment. Dont assume anything. Equipment tends to break down at the worst
times. Double-check to be certain all equipment is functional.
Treat the patient, not the monitoring devices, numbers, or diagnosis.
Not every patient with hepatitis or cirrhosis is an alcoholic.
Not every alcoholic will go into delirium tremens.
Do not assume patients are anorexic just because they look malnourished.
Do not assume patients are well nourished just because they are obese.

Assessment and Data Collection

Learn to assess pain without leaving out important data. Suggestion: use the COLDERRA
method where C = characteristics, O = onset, L = location, D = duration, E = exacerbation,
R = relief, R = radiation, and A = associated signs and symptoms.
Begin with the basics and keep reviewing them: airway, breathing, circulation (ABCs).
When you see acute changes in level of consciousness, first check oxygenation status.
Become a keen observer; use all your senses.
Be sensitive to hesitation and nonverbal cues when gathering information. What is left unsaid
may be extremely important. Use phrases such as Could you tell me more? or Could you
help me understand? to elicit more information.
Dont be distracted by the obvious. Keep looking!
Formulate a systematic way of assessing patients, and make it a habit. Go through the same
sequence every time. You will be less likely to overlook or omit something.
You cant find something if you dont look for it.
Dont trust (1) machines, (2) numbers, or (3) what you cant see.
Occasionally ask an experienced nurse or instructor to watch you do your assessments. Everyone, no matter how experienced, can benefit from objective suggestions for improvement.
Over time, it is easy to become sloppy or start forgetting important things.
With the first assessment of your shift, check the patients ID bracelet and the rate and type
of every fluid infusingyou are responsible for fluids under your control from the moment
your shift begins until your shift is over.
Remember to auscultate before palpating: Watch! Listen! Then Touch!
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Testing pH of nasogastric tube (NGT) drainage is easier if you slip the litmus paper into the
end of the NGT and reconnect the tube to suction. Drainage will be pulled over the paper,
which can then be removed. (Of course, antacids in the tube will negate this.)
Any abrupt change in color or amount of drainage from wounds or drains needs to be explored
and reported.
Do not suggest words to describe feelings or events to your patients. You may miss subtle
nuances if you jump to conclusions; listen to what your patients have to say and the words
they use to say it.
Perform a thorough psychosocial assessment that includes taking the values of patients and
their significant others seriously.
Include the significant others when you assess sleep patterns. They may be able to tell you
more about snoring and other sleep disturbances than the patient can.
Accurate recording of data, such as intake and output (I&O), is a must. Lawsuits have been
wonand lostover one single I&O sheet. Involve the patient and family in helping to keep
accurate records. Ask them to let you know about foods or liquids brought in to the patient.
Always double-check calculations; use a calculator, if necessary.
Acute cardiovascular and musculoskeletal injuries require frequent evaluation and documentation of the 5 Ps: pulse, pallor, pain, paresthesia, and paralysis. Deterioration of status in any
of these variables may indicate a medical emergency and requires a rapid response.
Be alert for substance abuse as an underlying diagnosis in individuals whose hospitalization is
sudden and unanticipated. Many nurses have been injured by patients in undiagnosed withdrawal. This may be a particular risk in motor vehicle accidents (MVAs) or medical crises in
which alcohol or drug use may be contributing factors.
Often patients and families will deny the existence of mental illness or abuse because of stigma
or ignorance. Ask about family violence (verbal or physical) or suicide very carefully.

Understanding the Problem or Diagnosis

You have gathered your information; now look at it. Do you see any patterns? Do the data
fit the history? Do all medications fit the diagnoses? Are all diagnoses accounted for in the
medications?
Ask the following questions:
Do the data make sense in the context of this patient?
Do the data create a complete picture?
Do you need additional data?
Use the data to formulate your list of patient problems.
Prioritize specific problem statements, and guard yourself against distractions.
Never think you are too smart to look something up.

Developing Strategies of Care

Plan and coordinate care with your patient. By discussing interventions and priorities, you
will learn more about your patients value system.
Educate the patient as you carry out this process; process and outcomes can and should be
integrated. A better-educated patient is more prepared to cooperate with the medical and
nursing care regimen.
Always include relationships, cultural orientation, self-esteem, and emotional issues in planning
care.
Prevent infection. Teach your patients and their families to wash their hands properly. Take
them to the sink in the room and demonstrate handwashing techniques that you were taught
in Nursing 101. Show them how to use a paper towel to turn off the faucet. Have them
practice.
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Watch other health care providers to ensure they wash their hands. If you are training others
who are with you, leave the water running in the sink as you leave the roomit is a strong
hint for them to wash their hands as they follow you out!
Check equipment; double-check if you have any doubts. You are responsible for reporting
equipment that is not in working order. Equipment not in working order can result in shock
or other forms of injury to personnel, patients, or families. Remove it from the room
promptly, label it clearly with a brief description of what is wrong, and report it according
to policy.
Substance abuse is not an uncommon complication in the recovery of trauma patients. Consider a psychiatric nurse practitioner or social services consultation if you suspect this is a
problem.
Accidents or injuries can aggravate feelings and memories associated with earlier experiences
of trauma and abuse. If responses to current health problems seem to be unusual or in excess
of what is expected, consider consulting a psychiatric nurse practitioner or someone from
social services.

Carrying Out the Care Plan

Frequently check your patients charts for STAT orders.

Document everything you do; if it isnt charted, you didnt do it.
Document the patients response to treatments, medications, and activities.
Let the patients values and preferences guide you.
Get the family and significant others to help, if appropriate.
As the patients resting respiratory rate doubles from baseline, he or she will need to be intubated and placed on mechanical ventilation.

Evaluation and Reevaluation

Monitor carefully for changes, whether dramatic and sudden, or subtle and gradual.
Include the patient and families in helping to evaluate care. Ask, Do you feel that what we
are doing is helping you? What do you think?
Is the patient getting better? If so, continue with the plan. If not, reassess and revise the plan
as needed.
Evaluate patient and spousal cooperation. Never label patients as noncompliant. Determine
why patients do not take their medication, complete treatments, etc. Perhaps the side effects
of treatment make patients feel worse than the disease, and they are exercising their right of
choice. Remember, noncompliance on the part of patients is more often knowledge
deficit or ignorance on our part! Noncompliance is rare when there is true teamwork, and
it is a misleading term. Adherence is a better, less judgmental word.
Long-term problems, particularly fatigue and pain, often contribute to depression.
Involve other health care professionals and pain specialists in addressing complex issues.

Teamwork Is the Key to Survival

When you graduate and start working as a nurse, you will be expected to be a team leader,
coordinating the patient care given by certified nursing assistants, other nurses, and students,
with the care given by many other professionals. Use this opportunity to observe the nurses
you think are the most effective in promoting teamwork. Analyze why they are effective, and
try integrating those techniques into your own practice.
Work at developing good relationships with other professionals. The health care system is
complex and constantly changing. We all need and deserve respect. We also depend on one
another.

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Pointers for Students: How to Look Like You Know What Youre Doing

Getting to know the medical nutritionists (dietitians), pharmacists, physical and occupational
therapists, psychologists, social workers, case managers, laboratory personnel, nurse practitioners, medical staff, pastoral counselors, and other professionals in your setting can make things
a lot easier for you later on. While you are a student, learn as much as you can about the
role of each professional and the most effective ways to interact with them. It all adds up to
good patient care.
Patient care settings can be stressful, high-pressure environments, especially in emergency
situations. Some of the most important things you can remember are:
Try to sort out the difference between fact and feelings.
Be forgiving.
Never take anything personally.

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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