[mrod]

I am a new grad since July working on a tele floor. I have a great preceptor that teaches me alot of things, has patience and a personality. I am basically on my own but with that preceptor "crutch" for another 4 weeks (by myself Nov 2nd) and things are going well. Yes, it is overwhelming but it does get better everyday.
I work overnights from 7p to 7a. My assignment can be anywhere between 3 to 5 patients which 5 is the max. I am a little anxious about seeing my patients and the time I am taking before I see them.
I get in around 6:45 and start looking up my patients in the computer. I am looking at PMH, triponin levels, any BNP's, TSH and all other labs including aptt and INR (even though I do not give the coumadin, that is another thread question I will be sending) anyway, I also look up who is consulted and why, tests to be done on my shift or the next am, etc. Now lots of times when the RN leaving gives report they start to talk to my preceptor only which bugs me because they ALL know I am still with her but if she is sitting somewhere else I have to leave my computer and walk over to where she is and listen without looking up things as they talk. See, she is looking up in the computer she is at as they talk. So I am thinking this could be a reason why I am so slow but not really by that much. So by the time I look up say 4 patients, get report it is about 8:15 p. I get my VS and do my assessment on all my patients, it is now about 9 pm and then I combine most of my 8's and 10's together unless I have a couple of BP meds that I can give at 11.
So, when does everyone else see their patients? I literally feel like I am running around with my head cutoff from 6:45 to about 1 in the morning! Is this normal or am I just way to slow? I just do not feel comfortable not knowing most about my patient before I see them and doing a good assessment I believe is important. Also, some RN's look at the chart while researching, how can they have the time during then to do that! I don't!!
What is everyone elses routine, any suggestions?

[KeechieSan]

Originally Posted by mrod

So, when does everyone else see their patients? I literally feel like I am running around with my head cutoff from 6:45 to about 1 in the morning! Is this normal or am I just way to slow? I just do not feel comfortable not knowing most about my patient before I see them and doing a good assessment I believe is important. Also, some RN's look at the chart while researching, how can they have the time during then to do that! I don't!!
What is everyone elses routine, any suggestions?

This is my routine at night, and it generally runs very smoothly. I work 7p-7a on a tele unit, my normal pt. load is 4-6, usually 6. I get to work at 6:15p, immediately look at my kardex's for the night and start my report sheet. I usually finish that around 6:30-6:45, so I go and write down med times. I usually get report from the day nurse at around 6:45, and that usually lasts until 7:10ish. After that I go 'round on all my patients, checking 02 sats and just seeing if they need something.. just getting a quick peek. After that I go and look up labs quickly, just to make sure that there is nothing I missed. By this time it is 7:30ish, I start my assessments then. Depending on the acuity, I am usually done by 9pm. I do accuchecks and give 9,10oclock meds. After that is done, most of the patients just want to sleep anyway, so from 10pm to 2am is usually the time I use to look in charts, read progress notes, just generally learn more about these patients so i can give a good am report. I do chart checks around 1am and spend the rest of the night doing odds and ends. Of course, this is an ideal night. Usually it doesn't run quite smoothly, but hey its a hospital, it will never run smoothly Someone always attempts to get out of bed and gets their catheter stuck, or poops on the floor, or is having excruciating pain. Its the unpredictablity that I really love.

[RN1989]

First off, the reason other people can do so many things in a shorter amount of time is one of two reasons: they either have more experience than you do so they have their routine down and do not have to take as much time as you do to process all the info and plan things out, or - they aren't doing a lot of other things that they probably should be doing. So relax. Once you have more experience you will find that you don't take as long to do these things either.

When you receive report, the staff should be giving you any pertinent lab results (high PTT, low H/H, high creat, elevated troponin, etc) just as they should be telling you about any abnormal vs. They should also be telling you if there were any labs ordered for you shift (timed, routine, etc). This is just like telling you what the accucheck was or abnormal vs. You should be giving report to the next shift in the same manner. This ensures continuity of care and that things are not overlooked. If this is not occurring on your unit - start doing it yourself. This is pretty much standard everywhere and perhaps the staff have forgotten it. Also, continuity of care is a big JCAHO deal! Besides, nothing sucks worse than to get report and the off-going nurse forgot to tell you that the pt's troponin was high and that you had another troponin due at 2100 and it doesn't get drawn and you get in trouble.

After you get report and check your med times if possible- ALWAYS see your patients first thing. See your most critical first (one on a gtt, newest back from cath lab, pt calling for pain meds, etc.) If your patients are chatty, explain to them that you can chat later but right now you are just getting on the floor and need to make sure that all the other patients are ok before you do anything else. See all your patients, begin charting if you can. Start meds. Labs are good to know, but unless you are going to have to give a med that is dependent on knowing a particular lab, you don't need to know ALL the labwork done for the day right when you get there. This is no longer nursing school. Real nursing means you do a focus assessment - this includes only looking at labs that are pertinent to what you are doing until you have more time later. And if everyone was giving a good report, you would not be needing to spend large amts of time looking up labs anyway.

From reading your post that you don't feel comfortable going to a room without knowing everything about your patient - this is hindering your time management. This is what students do. In real life, you can't do this. If you feel that you can't do your job without completely researching each patient, then you need to either get a different job or come in early, research your patient on your own time and then clock in at the correct time. Yes, one of those super complete assessments like you do in nursing school would be great, but the fact is, this is not nursing school anymore. You have to focus on the most important things. If they are there for CHF, your assessment goes something like this: VS (if no CNA to do them); heart sounds; lung sounds; check pedal/leg edema while checking pedal pulses; ask about pain; ask about SOB. If they are talking coherently, obviously their neuro status is intact. While you are checking for edema, you can be asking them all kinds of other questions to get a better idea of what is going on. While you are doing all this you will also be noting if they are wearing their O2 or not, how many liters they are on, if they have ok urine output by looking at foley/urinal, if they are SOB just talking to you or if they get SOB by sitting up in bed to lean over while you are listening to lungs. This can also tell you if they can move well in bed or if they may need assist - which can tell you if they are weak or not. If they aren't getting oob much you will want to check their skin, but not at the first of the shift. You can do that on your second time in their room while you give them fresh ice, empty a urinal, give 7-9pm meds. Your first assessment is the one that tells you if they are alive, if they are AOx3, if they are stable, and if there is something else you might need to look at later but is not the highest priority. It is amazing how much you can learn simply by watching the patient reach for the remote control, or by asking questions, etc.

You report having problems with the staff giving the preceptor report and not you. My guess is that you are still giving off the "I'm a student" vibe instead of the "I'm the nurse" vibe. By going to the computer to look up labs, you appear to care more about what is in the computer instead of what the off-going shift has to say. YOU are the nurse. Clock in, write down your assignment, get your kardex, then go find the nurse. YOU need to take the initiative and find the off-going nurse and say "I have rooms 202, 204, 206 and I'm ready for report". If they aren't quite ready, then sit next to them until they are. Chances are, they will get ready for report because they don't want to feel like you are looking over their shoulder waiting for the. Since you may not have been doing this, they will likely be surprised and maybe a little freaked out, but they will start getting the hint that you are ready to take on the role of nurse and will start speaking to you instead around you.

You CAN do this. It just takes time to get your routine down. Watch other nurses (other than your preceptor) and see what their routine is. Write down different routines and try them till you find one you like, then make it your own, adding in your own special things that you do. You are the nurse now. Show confidence. Doesn't matter if you are scared to death inside. If you don't know something, ask. But don't apologize for not knowing something and "bothering" someone. Simply say "Can you tell me.....?" Sounds like you are still stuck in nursing school mode and this is causing you anxiety. You are the nurse now. And one day you will be able to relate to the newbie on the floor and help him/her figure out how to do things in the "real world".

[StudentNurseInWNY]

rn1989, you gave excellent advice to the op. Good tips for planning out the beginning of shift too.

[mrod]

Wow, thank you so much for the advice.
After reading your reply and then thinking, I have not really transferred from student nurse to RN. I think it will come in time but your reply really put it into perspective.

The only question I had is when you were talking about the labs. Someone told me on the floor that you should have all the labs so if you need to talk to the doctor you can have everything in front of you. I know it is available in the computer, butwouldn't it just be helpful to have it in front of you? How about if there is a code on the pt, you have the info.
I was thinking about caring around the report sheet with me from the night before. It is a profile sheet that the last shift works on and then continues, like you mentioned about continuity. Although it is not "required" on our floor so some write the report and some don't and that is okay.

I will get this and thanks again

[RN1989]

It would wonderful to be able to see ALL the patients labs every shift but it isn't always practical. That is why in time you will learn which ones are the most pertinent to your pt and what treatments/meds you are giving. When you call a doctor, you should have the chart with the pt's lab work in front of you. It is not practical to write all the labwork down to carry around with you. When you call a doc, you may need to be looking at all the labs for the last several days so that you can tell the doc what the trend in the labs was. When a pt codes, the pt's chart should be in the room for ready reference, as the labwork should have already been printed by the lab and posted in the chart. Again, it is not practical to have the lab results of every single lab on your person. The more experience you get, you will figure out which labs that you need to keep track of and put on your "brains" to carry around with you during the shift. The rest needs to stay in the computer/chart till you need them.

[David's Harp]

Originally Posted by mrod

Wow, thank you so much for the advice.
I will get this and thanks again

At least some thanks should go to you, for asking a question that elicits info that I (and probably others) can really use. This transition into the RN role is definitely not a given once we have the letters next to our name, but having this in front of you will help speed that transition along. Ditto for me.

[agent66]

Originally Posted by KeechieSan

This is my routine at night, and it generally runs very smoothly. I work 7p-7a on a tele unit, my normal pt. load is 4-6, usually 6. I get to work at 6:15p, immediately look at my kardex's for the night and start my report sheet. I usually finish that around 6:30-6:45, so I go and write down med times. I usually get report from the day nurse at around 6:45, and that usually lasts until 7:10ish. After that I go 'round on all my patients, checking 02 sats and just seeing if they need something.. just getting a quick peek. After that I go and look up labs quickly, just to make sure that there is nothing I missed. By this time it is 7:30ish, I start my assessments then. Depending on the acuity, I am usually done by 9pm. I do accuchecks and give 9,10oclock meds. After that is done, most of the patients just want to sleep anyway, so from 10pm to 2am is usually the time I use to look in charts, read progress notes, just generally learn more about these patients so i can give a good am report. I do chart checks around 1am and spend the rest of the night doing odds and ends. Of course, this is an ideal night. Usually it doesn't run quite smoothly, but hey its a hospital, it will never run smoothly Someone always attempts to get out of bed and gets their catheter stuck, or poops on the floor, or is having excruciating pain. Its the unpredictablity that I really love.

If your shift starts at 7pm, why are you there so early? Our night shifts starts at 715 and I get there at 7 if I am lucky because 1) i don't get paid before 715, 2) the kardexes and orders/Mars from days aren't ready till at least then anyway, and 3) daystaff sometimes think if you are there early and something going on with the patient you are going to have for nights then maybe you should go help out. We have 7 patients at night, cardio and cardiac surg mix, sometimes a day 1 post cabg (5pt assignment) and admissions on evenings from emerg, plus returning post cath/ablation patients at change of shift that need frequent vs and groin checks. I have been nursing almost 20 years , 10 of which have been in cardiac and to boot consider myself extremely organized, I would find being "done" by 9pm a very, very quiet night. Not unusual at all to find a K+ of 3.1 on a surg pt that was missed on days at 11pm or later and having to wake them up for a supplement or a positive WBC on a post valve patient and nobody has notified the docs. I don't think the 11pm time is unrealistic at all for someone new.

[Spatialized]

RN1989 covered the bases in an awesome way . You will find your rhythm, it just takes awhile.


I found that by trying to be organized from the get-go, my shift goes better. I rarely look up labs since they are on the report sheets we get from days and hopefully the day nurse can give me a heads-up. After I get report I head to look at orders and MARs, looking for med times and any orders that need to be taken care of on my shift. Usually I'm heading into my first patient's room by 19:30 (shift starts at 19:00). Start with the most critical and go from there. If things go like they should I'm done with my first set of VS & assessments and ready to pass meds starting at 21:00. I even have strips on everyone and have taken a quick look at stuff in the computer. But I too run until about 00:30, then things start to slow down. I can do chart checks, sign off MARs and get ready for the inevitable admit (unless I have 5 already).

Then again, it took 6 months to really get to the point where I felt confident about this and my skills. You will too, it just takes time. Like said above, take the initiative to stand up and phase out the "I'm a student" to "I'm a nurse."

Good Luck!
Tom

[al7139]

Hi,
I hope my advice helps you. I am also a new grad on a telemetry unit. We use tape recorders for report as well as do walking rounds with the outgoing nurses. My routine is this: I get my worksheets, then go listen to the recorded report. Most pertinent labs are reported, but I will have the pts labs up on the computer to confirm, or get new results that were pending when the report was taped. We use report sheets that the nurse records her assessment on as well as abnormal tests, nursing care issues (i.e. crush meds, no B/P sticks in __ arm, etc.), and vitals for the shift. I also look at what meds I will be giving, and the times, as well as labs that need to be drawn, fluid or IV drips the pt is on. I then write my own notes based on report, and questions I may have for the nurse (Has this lab been done? Does the pt have parameters for meds, etc.). We then do walking rounds, where I look at the chart and new orders from that day, introduce myself to the pt and check the fluids/drips hanging with the other nurse. I also check the IV site ( I have found several infiltrated IV's this way, and I make sure the outgoing nurse deals with the paperwork before she leaves...always check your IV sites frequently!). If the taped report tells me the pt is A&Ox3, and the pt is lethargic and confused when we do walking rounds, the outgoing nurse needs to call the doc, not me. This may sound like I am difficult to work with, but since it is my job and my license, I will always make sure the outgoing nurse deals with these issues before they leave. Nothing is worse than calling a doc and saying "I have no idea whats going on, I just got this pt 20 minutes ago." You will gain experience as you go, but it is easy to see if there are problems if you insist on rounding at the pts rooms and seeing the pt with the outgoing nurse. If your unit does not do this, you should suggest it to your manager. You would be surprised at how much it cuts down on problems with pt care. The most important things are these: Is your pt being handed off to you in the condition that is being reported? Is the MD aware of any critical labs or test results? Is the pt receiving the correct fluids at the correct rate? Is the IV patent? Are any drips (Nitro, Cardizem, Amio) that are hanging correctly calculated, and is the bag current (in my facility any drips need to be changed every 24 hours)? What PRN meds were given and at what times? These are the most important basics...anything more in depth you can do on your own shift.
BTW, don't let another nurse tell you that she ran out of time, so that's why you have to do...whatever. If it's scheduled on their shift, they need to do it!
Hope this helps,
Amy