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Showing posts with label clincial. Show all posts
Showing posts with label clincial. Show all posts

Saturday, October 5, 2013

Guide To Clinical Paperwork

Clinical




Here's An Example Of A Patho That Passed
copyright Janice Silbermann :)

Diabetes Mellitus
Disease of deficiency or resistance to the effects of insulin. Cells use insulin for energy needs. Insulin also promotes fatty acid storage in the adipose tissues. Type 1 diabetes is an absolute deficiency in insulin and type 2, which has a later onset and is related to diet and life-style choices, is insulin resistance.
Diabetes has a hereditary component in both types and along with obesity is a risk factor. High cholesterol, triglycerides and high BP also constitute risk factors
Diabetes puts a patient at risk of multisystem complications including peripheral vascular disease, heart disease and renal disease
Hyperglycemic symptoms include polyuria, polydipsia, weight loss, fatigue, weakness and frequent skin complications such as infections
Tests include fasting plasma glucose levels. A reading of > 126 mg/dL is considered high. Random blood glucose testing may reveal a level of >200 mg/dl. Oral dextrose (75g) is given in the third test and a BG level is obtained 2 hours later. A reading of >200mg/dL is indicative of DM.
Treatment includes changes in diet and exercise. Type 1 requires insulin replacement as the body is not manufacturing insulin. Type 2 may be treated with oral anti-diabetic drugs which will stimulate the body to produce insulin or increase sensitivity at the cellular level. Injected insulin may also be used in Type 2. Dietary measures include a consistent carbohydrate diet, which is calorie controlled to maintain optimal weight. The diet is carefully calculated to keep BG levels in optimal range.
Insulin can be characterized by its rate of onset, peak and duration. Rapid (lispro), for example has an onset of fewer than 15 minutes, while Lente has an onset of 1-3 hours, but lasts 18-24 hours in contrast with Lispo’s 3-4 hours duration.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001153/
http://www.mayoclinic.com/health/copd/DS00916
http://www.lung.org/lung-disease/copd/
http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-exams-and-tests

LeMone, P., K. Burke, and G. Bauldoff. Medical-surgical nursing: Critical thinking in patient care. Fifth. Upper Saddle River, NJ: Pearson Education,Inc., 2011. Print.




Great H-T-T Assessment Guide

Here's An Example Of A Physical Assessment That Passed


Neurological: Not oriented to person, place and time. Unresponsive to verbal commands. Withdraws from stimuli. Pupils equal, round, reactive to light. Sluggish pupil response, 6cm bilaterally, accommodation present. Unable to assess hand grips. Bilateral ankle dorsificaton and plantar flexion, equal, weak.

Pulmonary: Trach present. control assist ventilator, Vent Settings:  Mode: assist control     FiO2:40%  Rate:14    TV:420mL   Vmax:50L/min  Respiratory rate between 17-26 during 8 hour shift. Tachypnea. Breathing labored and shallow, bilateral, equal use of accessory muscles, no retractions. Chest rise equal bilaterally. Rhonchi present upper left, upper right, lower left and lower right lobes. No cough.
Moderate secretions, thick, blood-tinged.

Cardiac: Apical pulse 0800 -108bpm, 1000-119bpm, 1200-107bpm,1400-96, strong, regular. S1 and S2 present. No murmurs heard. Sinus tachycardia. HR between 97-140 during 8 hour shift.
BP: 0800-141/74 1000-134/61 1200-101/42 1400-11/48-automatic cuff, left arm, taken supine.
Radial pulses, equal 3+ bilaterally. Doralis pedis pulses equal, 3+ bilaterally, tibial pulses equal 3+ bilaterally. Cap refill right hand <3sec, left hand <3 sec, right foot <3 sec, left foot < 3sec.
Pitting edema 4+- bilateral hands, feet, thighs, ankles. Pitting edema 1+ above knee. Pitting edema 1+ above elbow. Facial edema present.
No JVD present.

GI/GU: Abdomen soft, round. Bowel sounds heard immediately in all four quadrants. No rebound tenderness or masses. Bowel movement 0930 1-28-13, soft, formed, brown, no foul odor. zero residual in g-tube. Auscultation shows correct placement.
Urine clear, dark yellow. Foley catheter. Tube feeding with Nova Source Renal 30 mL/hour. NPO.

Musculoskeletal: Passive ROM in all extremities, unable to move spontaneously. Unable to assess neck range of motion due to edema and presence of trach collar. Gait and posture unable to assessed-non-ambulatory.

Integumentary: skin color normal for ethnicity. Skin warm  and clammy on palpation. MM moist, pink. Not tenting in upper extremities. Lower extremities edematous, skin tight and shiny. Nail color pink. No clubbing observed. PICC line present right antecubital. Dressing dry and intact, no drainage, no bleeding.
Large area of reddened, denuded, sloughing skin both buttocks, both things, sacral area, moist.

















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Sunday, September 22, 2013

Dignity Is Up To You





Mental Health
Clinical

I have a hypothetical scenario for you to ponder. One day it’s possible you will have two patients on your floor- one who is fighting to stay alive because of a physical illness and one who is fighting to stay alive because of the demons in her head.

Both patients might have families. Both families might look harried and scared. The family of the patient who is physically sick will talk openly with the nurses and be consoled by them. This family will have no qualms about talking with the nurses in the hallways or at the nurses’ station. The nurses will hug them and express sympathy. But the other family, the family of the patient on suicide precautions, will talk only in hushed tones in a darkened room. The nurses will not know how to react. The nurses will not know how to comfort.

Mental illness is treated differently in society than physical illness. Even now when we know so much about its causes. Even when we know that it is not something that someone can ‘snap out of’ if they would just try hard enough. As a nurse it would never cross your mind  to think that your patient just needed to try a little harder to overcome their physical illness.  You would never think things like, “Well, what is she doing being sick? She has so much to live for. I just can’t understand it.” Or, “Gee, maybe she should just stop thinking about being sick, it would be fine. Why is she so weak?” It will almost definitely cross your mind to think similar things about your psychiatric patient.

As a nurse you might see that the patient with the physical illness has love and support from many people. Her room is filled with visitors and balloons proclaiming “Get Well Soon”. The patient with mental illness will have no visitors. Friends may have run a long time ago, family might be weary of dealing with the situation. There will be no flowers or balloons.

So you might see all this. The question becomes what are you going to DO about it? How are you going to talk to your fellow students and later to your coworkers?

Your mental health rotation is the place to begin to learn empathy for psychiatric patients. To realize they deserve dignity and support. Going to the AA meeting is an inconvenience for you. An annoyance. Think, though, of the tremendous amount of courage it takes for an alcoholic to walk into that meeting for the first time or to keep going week after week. Think of the amount of courage it takes for someone to admit they need some psychiatric help and to check themselves into a psychiatric hospital.

You will see a lot in your mental health rotation. Your job as a clinical student is to develop you therapeutic communication skills and to learn the symptoms of each illness and to know the side-effects of psychotropic meds. But your job is also, though you may not know it, to develop an approach to dealing with psychiatric patients that preserves their dignity and humanity. You may have no desire to ever be a psych nurse, but you WILL see psych patients in every other facet of nursing.

These should be your primary objectives:
“Treat the patients with dignity and respect at all times. You will never regret it. Try not to be afraid of psychiatry or psychiatric patients, you cannot catch madness. Mental health stigma and prejudice is real and widespread. Make sure you are not part of the problem.”  You have a unique opportunity as a nurse just starting out whose opinions and attitudes are still being formed. How are you going to treat the two patients on your floor in my hypothetical situation?


[http://www.shockmd.com/2011/09/07/tips-when-starting-psychiatry/#sthash.vlBri9Ll.dpuf]
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Sunday, August 4, 2013

Different Types Of Clinical Experiences, Different Types Of Nurses


Clinical
Dosages
Adult Health 1
Peds
OB
Mental Health
Adult Health 2





These Videos and articles will help you understand just what to expect in each clinical setting and what differs between them. How you progress from Foundations to ICU (which sounds much scarier than it actually is).
Foundations

 This is the very basics. Learn this stuff well-it's important. Practice on everyone who will let you. We go into the community to do some service learning... that's where you will learn to take a manual blood pressure really, really well and then never take a manual blood pressure ever again in the clinical setting. 

 A nice quote about your responsibilities:

  "The student nurse has the responsibility of observing procedures, documenting procedures that she performs and practicing her nursing skills. Prior to meeting a patient, she reviews the patient's medical record and familiarizes herself with the patient's condition and treatment. The student also follows the rules and regulations of medical facility. In meeting the clinical rotation objectives the student assesses the patients mental and physical condition, defines the patient's health problem then makes and implements a plan of care. The instructor supervises the student and assumes responsibility for the student's actions."

Read more: http://www.ehow.com/info_8624952_nursing-objectives-clinical-rotation.html#ixzz2b1gJzTgn

 One of the sections is taught at the Memphis Jewish Home- this one is a little more challenging because you will not get any charting experience and although older, he patients are relatively 'healthy'. It is a different kind of nursing than bedside nursing. This is a good place to learn to interact with all kinds of people and maybe put the principles of cultural sensitivity into practice. My motto is-there's always SOMETHING to learn even if it's not what you thought you were going to learn. You will learn how to chart later, I promise.




Adult Health 1

My first patient in AH1 was so complicated, I almost quit that day. Tubes everywhere (including a rectal tube- gotta love those), restraints, machine, tons of meds. What a difference from the quiet nursing home. I did not sit down the entire day. I was overwhelmed  but kept plodding along and learned a whole lot about time management. That was my first introduction to just how hard nurses really work.


OB

Students either love OB or hate it. The guys have a hard time with this one, for sure.  This clinical is more hands-off than other clinicals  you have to find creative ways to use your time. OB clinical is, however, a great way to meet new people :) That was a joke. Get it? NEW PEOPLE-oy!


Peds

The pediatric rotation addresses issues unique to childhood and adolescents by focusing on human development and emphasizes the impact of family, community and society on child health and well being. This is an excellent opportunity to apply some of the social principles we are taught-seeing the child as part of the whole family, interacting with all members of the family


Mental Health

Since only 4% of RNs work in the mental health field, I am assuming this is NOT everyone's favorite clinical rotation. 



Adult Health 2

This quote pretty much sums it up:


"In the intensive care unit (ICU), nursing students have the ability to learn about the complex health issues of critically ill patients, practice selected technical skills, and develop communication skills. There are both benefits and challenges to having nursing students in the intensive care setting. With preparation, the student is able to immerse in the ICU environment, acquire new knowledge and skills, and participate alongside the nurse caring for critically ill patients. "


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Friday, August 2, 2013

Skills

Clinical




SKILLS
Do remember that a lot of videos are available in PAWS
I think I might watch all of these before I start working.



























IV and IV Piggyback

SKILLS SITES WITH LOTS OF VIDEOS




These are kinda cool, but they cost $1 each.




AVAILABLE ON EVOLVE



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Sunday, June 30, 2013

Solutions To Dosages

Clinical
Dosages
Study Guides



 Some people are not so happy about this class because it involves numbers and stuff and a lot of people do not like numbers.

 And just remember when you're taking those clinical dosage tests, you have FOUR tries. How fun- you get to work yourself into a  nervous frenzy four times (then you fail). Just kidding, I don't actually know anyone who didn't make it at least on time #4. 

 Nothing can make me lose sleep like a dosages test and my hands sweat just thinking about it. Once my friend James said as a joke, "Math test today!" (he's a riot). Instant tachycardia and diaphoresis. Then five minutes later, my teacher said FOR REAL , "It's time for the math test." I had to be defibrillated. How did I miss that it was dosage test day?

 So in case you just failed test #3 or just want some extra practice for Dosages and Solutions, here are some resources:

PRACTICE SHEETS


This is REALLY REALLY REALLY good:




VIDEOS





(which is the same as American clinical math, just with a nicer accent)





APPS



Mr. S's Rounding Rules:

 That sounds like a kids' show or something

(These are, like, official and stuff)

Zero Rules for Decimals
1.    All numbers less than 1 must have a zero placed before the decimal point.
a.    Example:  .5 should be written 0.5
b.    Example:  .032 should be written 0.032
2.    Leave no trailing zeros after the decimal point.
a.    Example:  3.0 should be written 3
b.    Example:  5.380 should be written 5.38
c.    Example:  6.2003700 should be written 6.20037

Decimal Rounding-Off Rule
1.     Determine to which place value to the right of the decimal point you are rounding off the number.  Look at the digit following that place value.
a.    If that digit is 5 or larger, then drop that digit and add 1 to the previous digit.
                                          i.    Example: 5.26 rounded to the tenths place = 5.3
b.    If that digit is 4 or less, then drop that digit.
                                          i.    Example: 5.234 rounded to the hundredths place = 5.23
2.    Weights and Temperatures should be rounded to tenths.
Syringe Selection
1.    Dosages more than 1 mL in volume should be calculated and rounded off to the tenths place and then administered in a 3-mL syringe.
2.    Dosages less than 0.5 mL in volume should be calculated and rounded off to the hundredths place and then administered in a 1-mL syringe.
3.    Dosages more than 0.5 mL and less than 1 mL in volume can be calculated and administered in either a 1-mL syringe (round calculation to hundredths) or a 3-mL syringe (round calculation to tenths).
IV Rounding
1.  IV rates calculated in drops per minute (gtt/min) should be rounded to the appropriate whole number.
            a. A calculated rate of 12.6 gtt/min is rounded to 13 gtt/min.
            b. A calculated rate of 14.2 gtt/min is rounded to 14 gtt/min.
2.  IV rates calculated in milliliters per hour (mL/hr) should be rounded to the appropriate whole number.
            a. A calculated rate of 84.5 mL/hr is rounded to 85 mL/hr.

            b. A calculated rate of 23.3 is rounded to 23 mL/hr.
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Saturday, June 22, 2013

How To Impale Yourself On An Alarm Clock And Other Tales From Clincial


Clinical

Ah, clinical...


EXPECT TO DO STUPID THINGS

 I managed to miss my first OB patient's birth. I went to do my my half-hourly check and she was sitting there with a baby in her arms. I thought, "Oh crap, I am in a whole mess of trouble." Sure enough I hear my clinical instructor from down the hall saying, "Where's Janice, I'm going to kill her."

 In OB I forgot the thermometer was attached to the wall with a really springy cord. I let it go and it pinged my patient in the face. Later she declined to have me put in a Foley for some reason.

 I wondered why the patient on the gurney with the sheet over his head did not want to see where he was going.

 I forgot to bring the GPS when we had to go to Arlington High School to do service learning hours. It didn't help that we stopped in Lakeland and asked someone at a gas station where Arlington High School was and he replied, "In Arlington, I would think."

 I didn't know The Med puts its toilets in a closet and was standing there with a container with 500mL of urine in my hand while my clinical instructor told me twice to empty it in the toilet. Man, was he having fun.

 I swear they sit around and tell 'stupid student stories' at faculty meetings or keep journals with entries that start, "Dear Diary, you'll never guess what my clinical student did today..."

 There is, however, a difference between stupid and dangerous. If you don't know how to do something, don't fake it- ask for help.
SOMETIMES IT GETS GROSS

 I had an instructor make me empty a rectal tube bag into the toilet right after we got back from lunch. It went something like this: squeeze, GAG, squeeze GAG, until she took pity on me and dumped the whole thing in a biohazard bag.
ORGANIZATION IS KEY

 Before:
  • Make sure your printer has ink
  • Iron your uniform the night before
  • Have a clinical 'checklist' posted with all the stuff you need
  • Have a bag designated for clinical that does not leave your car
  • Have each other's phone numbers and the instructor's if she allows it
  • Set Alarms. I had all three of my phone alarms on, my regular bedroom alarm clock and a clock I purloined from my daughter that was in the shape of a castle, with big pointy turrets. I actually slept with that alarm in bed. I lived in fear that one week I'd have to call in and say, "I can't come to clinical because I impaled myself on an alarm clock."
During:
  • Carry a notebook
  • Have sixteen black pens available
  • Know what you need to be doing at each moment
  • When a computer becomes available, grab it and chart
  • Make you own checklists. I made these and used them throughout clinicals:
KNOW YOUR STUFF

 The phrase, "I don't know" uttered from you lips during clinical is like the kiss of death. Anticipate questions that might come up. Make connections to what your learned in class. Know your meds. Every instructor I had at SW was very patient in helping me learn procedures, they were less patient if I didn't know what I was talking about.

 Bring resources and divide between you who brings what. Maybe the text, certainly a drug guide, a lab book guide, a procedures book.

 Remember the hospital computer has resources as well. You can look things up there. I spent time studying on the computers when things were slow and provided no one needed them.

 Resources that help you know your stuff before clinical:


BE ASSERTIVE BUT RESPECTFUL

If you need help-ask for it. Instructors are more than willing to help you, but remember they have seven students to tend to and your concern may not be a priority (there's a lovely NCLEX word).
Ask questions. I'd rather ask a million stupid questions than harm a patient.
If you feel like certain situations are beyond your control, speak up. One week I had an RN precepting me who did not want me to chart and my instructor asking me when I was planning on getting my charting done. When I finally spoke up, they came to a compromise and I stopped tearing my hair out.
I had an instructor who was obviously upset with me, but I did not have the presence of mind to calmly say, "OK, let's go talk about what I did, so I can fix it."
I did tell and instructor that I really wanted to do the blood draw before we left. He let me.

BE PROFESSIONAL

Never say in front of a client  "This is my first time EVER putting in an IV, I'm so excited." Think before you speak. Sometimes we forget the patient is even in the room while trying to talk to a clinical instructor.

Yes, sometimes you want to-don't. go in the bathroom for five minutes. You can go home and do what I did-dramatically throw yourself on the bed and say, "I am NEVER going back." Talk to your friend afterward, but stay professional.

When you are presenting your patient in post-conference and your classmate makes a joke and you want to die laughing, just carry on as if he hadn't spoken.

MAKE OPPORTUNITIES

Some clinicals are slower than others, but there is still a chance to learn:
  • Attend more than one C-section
  • Go to the morgue
  • Run a therapy group in MMHI
  • Help another student
  • Attend medical tests
  • Watch procedures like bronchoscopy and thoracentesis
  • Talk to the doctors 
  • Listen in when the doctors are teaching the interns
  • Interact with the family
  • Learn about a new culture
  • Attend classes the hospital gives for patients
  • Transport a patient
  • Talk to the CNAs
  • Watch post-mortem care on a dead baby, even if it is emotionally wrenching
  • Watch how your nurse calls and interacts with physicians
  • Talk to the patients beyond getting their history

MISCELLANEOUS TIPS
  • 6:30 really means 6:30. Some instructors consider 6:31 late. Believe me.
  • Mr. S has a way of sneaking up behind you when you are in the middle of a procedure. 
  • Ms. F is very laid-back and easy to work with.
  • Mr. K is extremely good at teaching assessment skills. Seriously great Foundations instructor.
  • Ms. L is scary, but you will learn an incredible amount from her.
  • "Park on the roof" means the first space where you can see the sky
  • Eating in the hospital cafeteria every week gets VERY expensive, but it's really hard to pack a lunch at 4:30 am, it's a trade-off
  • Scan your 'clinical passport' documents into your computer.
  • Turn your phone off.
  • Nobody looks at that clinical skills check-list thing after AH1, but know where it is until then
  • Clinical paperwork takes a really, really long time
  • Do not do those things that they put in the rules. You KNOW if they are in there, SOMEBODY did it at one time. Somebody was stupid. 
  • If you pick the clinical that is the day before the test day, don't despair. Think of clinical as a study opportunity  It was easier to answer test questions on halo traction when I had just had a patient in halo traction.
  • Do not try to do anything that requires thinking after clinical  do yourself a favor and go to sleep.
  • You get to evaluate your instructor in SET on PAWS. Then you can say things like, "Some of us learn better when we are taught with kindness and patience."
HITTING THE CLINICAL JACKPOT

 AKA things that make you want to do a little happy dance:

  • getting an open computer.
  • Getting an 'S' instead of an 'S minus' (or, god forbid, a 'U')
  • Your patient does not need accuchecks.
  • Your clinical instructor does not notice for 12 weeks straight that you glued you SW logo badge on your sleeve and the superglue kind of gooped out all over the sleeve.
  • You do not get blood, urine or food on your white pants.
  • You hate vomit and manage to go two years without a patient throwing up.
  • You hear the words, "We'll leave a little early today."
  • You get to go to the restroom twice.

GET THIS BOOK:

It's great--

Product Details

Remember that clinical is a taste of nursing. When you get out you will be a 'nurslet' as Dr. M likes to call us. Mr. K told me it takes a good six months to a year to feel fully competent  This is where you are figuring out what you want to be when you grow up.



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Monday, June 17, 2013

In The Beginning

Foundations
Clinical


 Ok, forget your perfect GPA. It's history (at least for most of us). 85 is an AMAZING nursing school grade. Just remember that. I asked  Mrs. M to write a recommendation for Denmark for me and she wrote, "She has very good grades." I had Bs. I laughed, but this is nursing school- different criteria apply. It always kind of bugs me when people look down their noses that I went to SW, I feel like saying, "But, but, you don't understand..." I also had a friend tell me before she entered Foundations that she was going to get all As, to which I replied, "Mmmm, hmmmm, get back to me."

 Along the same lines, Krystal has this good advice for LPNs: "Take it seriously. Just because you're a LPN doesn't mean you know the all information to pass. I went through the LPN to RN mobility track, & sometimes the thought process of the LPN's is "I already know that...." If you are a LPN, just listen & study. There is plenty you do not know!"

Darlene has this advice: "If you can do it and not work, DON'T Try to work full time! just way to much to try to learn and juggle a full time job."
 I concur. I saw many people have to drop out because their other demands were too many. That is not to say, it's impossible, but just know it will be a hard two years anyway. Anything you can do to simplify things is helpful.

 This is where you learn to think like a nurse. The nursing process and safety are the main concerns of this class. Again, this is information that you will need to build on for the rest of your career  They don't call it Foundations for nothing.

 This is also where you ought to start building your group cohesiveness that I go on and on about. I really cannot emphasize how important it is to have a support system and that pretty much has to be your classmates because those outsiders are clueless about this whole process. Start a study group. Work on objectives together.

 FOUNDATIONS STUDY SHEETS! YOU MIGHT REALLY WANT TO CHECK THESE OUT!

Yanawn put this in the comment below, but it's so important, I want to add it here:
"Also, get a GOOD study partner in the beginning that you can keep throughout the program. You should read on your own and meet to study what you already know. Going over questions together and being able to talk it out with someone is great! Even if you aren't getting them all right don't get discouraged. Read the rationales and each of you make a list to review later. Talking through the answer gives you a better understanding...."


Remember you have to do a project that goes something like this:
It's a hard project because you have to figure out how to get 4 or 5 very busy nursing students who live in different parts of town together to make a skit or video or game show. It seems like a waste of time, but I will say this over and over-ANYTHING you do to help you learn fluids and electrolytes is important. You need that knowledge forever. A theme is going to come up in this post-time management. Everything is about how you budget your time.
5 Tips To Taking Care Of Yourself As A Nursing Student

But prepared not to have much of a life for two years. Elicit the help of friends and family-you're going to need it.

Talk to all the nurses you know and do research about what specialty might be good for you. I love getting ideas from people who have been there.

CLINICAL

 TCPS takes way more time than you would think. I think the first time I did it, it took me at least 2 hours, probably closer to 3. So budget time for this because there is a lot of administrative business to take care of at the beginning.

 Talking of  the administrative stuff, it can seem a little overwhelming. this is where helping each other and having a Facebook group helps. You can remind each other of when things are due. One of my best organizational tips is to write things with a  dry erase marker on the mirror of my bathroom. I had a fair percentage of the class doing this before the end of nursing school.

 Get a good stethoscope and equipment. I did not buy the kit that SW offers. I got my own stethoscope  penlight, bandage scissors and EKG calipers. Get quality stuff-you will have it forever. I got a clinical bag and a good alarm clock or three. Buy a million black pens. You can buy all-white shoes at Payless. They don't need to be expensive, after eight hours on your feet even the most expensive shoes are bloody uncomfortable.

 And learn to do THIS really well...

I also had a 'checklist' on the door of my closet that was specifically for clinical. Reminding me of what I needed to bring

 The first six weeks of clinical are spent in the lab. I had Foundations clinical with Mr. K. Could not have asked for a better teacher to teach me the basics. Toward the middle of 4th semester I saw him coming out of the lab with a Foundations clinical group and it hit me how boring it must be to teach a bunch of newbies how to use a stethoscope  So I appreciate even more how diligent he was in preparing us. Your clinical instructors are your first line of defense in getting through this semester. They have a lot of knowledge to impart to you about every aspect of nursing.

 Practice your basic skills on your family members. I am not talking about putting a Foley in, here. Just basic stuff like pulses and breath sounds. Although, I have a sterile IV starter kit sitting on my shelf that I bought off the internet and everyone in my family is too wimpy to let me use it. Hmmmm.

 Remember that there are videos on PAWS to help you get basic skills down. Watch them-they help. As usual youtube is full of resources.

 Don't underestimate the importance of basic procedures. NCLEX now has 'hotspot' questions where you will be asked to click on things like where to palpate a liver and where Erb's point is. Learn it well now.

 Get a good nursing care plan book or two or three. Nursing care plans suck. Make it as easy on yourself as you can. Get a good drug guide. I didn't discover until the end of fourth semester that there was are  lab guide books. that would have made my life infinitely easier. You are going to be surprised at how long clinical paperwork takes. It was like having a part-time job. This is another time budgeting issue. Beside the clinical itself, the paperwork takes about 10-15 hours a week at first. Budget 15-25 hours a week for it in addition to class time and study time. The best words you hear in semester four are, "After this week there is no more paperwork." They might be among the best words you ever hear in your life.  And definitely DON'T ask someone ahead of you for their care plans. THEY know, I promise.
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