Quote from Sam.Dion
I am 20 years old and have started my first nursing job in LTC, and I was a CNA 2 years prior. I have been on orientation for about a month and have about 5 more days until I will be on my own, and I have never felt more overwhelmed. Med pass and Treatments I do fine with and manage my time fairly well, but when it comes to documentation like Progress Notes, when to call the Dr and what to even say, admissions, labs, etc, I lose my mind and I feel so lost. Are there any nurses who felt this way when they were brand new? And how did you cope?
I never felt like that.
I was overwhelmed with Med pass, and didn't know how or where to start with treatments or with managing my time. I could document fairly well (although some of my notes still come back to haunt me -- a good friend and former colleague still laughs about the note I wrote where my patient, who was confused, kept trying to chat with an Alaris pump and I wrote about that in detail!). When to call the doctor (and what to say) stressed me out to the point of diarrhea, admissions were completely overwhelming and labs? I remembered to draw them, but not to check them.
So, you're already doing lots better than I was!
Some of the job you're OK with -- make sure your preceptor agrees with your assessment of your strengths and weaknesses. If she does, ask for help concentrating on documentation, admissions and labs. (If she doesn't agree, that's a whole 'other thread.)
There's lots out there to read about documentation -- what you need to include and what shouldn't ever be included. Read what pertains to your situation and your system. That will help. In general, you want your documentation to reflect the assessments you made, any other data pertinent to the issue, your plan to address the issues and how things worked out. It should not include any subjective statements. For instance, my former colleague was correct in assessing that his patient had a reddened area on a boney prominence that looked like a pressure injury, that the patient should be turned frequently and kept off of that area as much as possible, and that the area should be monitored. He was wrong in including that "the night shift was clearly more interested in gobbling down pizza and watching Christmas movies on Netflix than in caring for their patients." That's a rather obvious documentation failure, but hopefully you catch my drift. If it helps, do a rough draft in pencil on your "brain sheet". Don't devote much time to this, or you'll get behind however.
No nurse is hatched knowing when to call the doctor -- that's something that comes with experience. Even after you're off orientation you can check with your colleagues about whether you should be calling the doctor about XX observation and the timeframe for doing so. You WILL call sometimes when you should not have, and you WILL decide not to call sometime when you should have. We're human, and humans make mistakes. You'll learn from those mistakes, just like we all did. It helps to have a solid set of criteria to use when making that decision. (That criteria has nothing to do with the doctor's tendency to yell when called.) Your facility may have specific guidelines such as call for a temp greater than 102, for a urine output less than 240cc/shift or for a blood pressure greater than XX/XX or less than YY/YY. If there is such a list, copy it and carry it around with you until you feel comfortable without it.
As for what to say to the doctor when you do call: take a moment to acknowledge their humanity. "Sorry to bother you on a weekend/holiday/night/when you're seeing other patients/whatever" isn't an apology for doing your job, but just a bit of social grease. Identify the patient and ask how well they know her. Her primary doctor who has known her since before her first period may need fewer details than the new partner in the practice who is covering for him. A format such as "SBAR" may help. (It may help with documentation as well.) State the concern, the supporting data and (when appropriate) a suggestion for how to proceed. (The last time she had a UTI like this, a X day course of Y antibiotic cleared it right up.) You may not know what to suggest, but your charge nurse can help you with that. The beauty of LTC is that you'll get to know your residents really well, and oftentimes will know what to suggest to a physician who doesn't know them. Have the chart and the labs in front of you when you call so that if they ask a question you hadn't anticipated, you'll have the information right at your fingertips.
And lastly, we all felt the way you do when we were new. AS you gain experience and learn more and more on the job, that will get better. Things get easier. You WILL learn to document quickly and appropriately, when to call the doctor and what to say. No reason to lose your mind. We all get it.