Shift Assessment, Preceptor Questions, etc

[Nurse SMS, MSN, RN]

So I have worked six shifts now on the floor with my preceptor and am taking two patients in conjunction with him. One of the things I am noticing is a definite sense of uncertainty when it comes to my assessment of the patient. I frequently find myself referring back to the assessments previous to mine for comparison and at times am tempted to change my assessment/evaluation based on what other nurses have found. That's when I call in my preceptor to see if he is getting the same impressions I am. But I have been kind of stunned to find things such as IV lines being documented as present in a certain place...and evaluation turns up no IV in that place at all....as if someone discontinued it and didn't document the d/c and the nurses following didn't notice it wasn't there anymore?

Documenting wounds continues to be my kryptonite. I feel my wound assessment skills are still pretty underdeveloped. I have a lot of resources and hope to improve this as time goes on. My preceptor is great about helping me figure this stuff out.

I have noticed my preceptor will jump in and do things without really discussing it with me - ie: ordering the IV team or a wound team consult, documenting something, etc. He is ultimately still responsible for the patient so this is understandable, but I am wondering if this is a reflection on me, missing stuff that I ought to be getting?

I am having such a hard time with "forgiving" myself for being new. I came from a career in which I was super efficient and good at what I did. Being new again and being so slow - I find myself having to reel in the urge to try and speed things up, check the task off, etc and to actively remind myself that fast isn't the goal right now - that safe and thorough are the goals. It is hard!!

[GGT1]

Most people look back at the last assessment...just don't copy it. An assessment is what you see, hear, feel....not what the last nurse did. But as a new nurse it's is sort of a reference. if you notice something not right on the last assessment, then all you can do is properly document your assessment with what you see (IV in different location, PU that was not documented, etc.) BTW it will get easier.

[ac3070]

I'm new too, and I definitely look at other nurses' assessments--I think it's helpful to see how the patient has changed in the last twelve hours. Obviously if something is super different than what I've found, I check again and/or ask my preceptor too. I'm in my fourth week of orientation, taking four patients now, and sometimes I get confused!

[dudette10, MSN, RN]

I, too, have noticed that certain parts of previous assessments don't match what I see. It's obvious in 75% of the cases that the previous nurse didn't assess it at all. For the other 25%, I was unsure of my assessment from the beginning, so I'll either go back and check the patient again or ask someone else to take a look/listen if it means an important change in the patient's condition.

As for the preceptor jumping in, you are only six shifts into your orientation. Give him some time to get to know you, to observe your strengths and weaknesses, and to evaluate your critical thinking. IMO, it's too early for him to just let you do your thing. If he continues to do so after a couple more weeks, i.e. he hasn't allowed you some independence by that time, maybe a conversation with him would be in order to find out why.