A day in the life of a Registered Nurse.... - page 3
The purpose of this thread is to give a better understanding of the Nursing feild to those who are working towards becoming a Nurse!... Read More
Oct 21, '06t'was really great reading your message. may i ask permission from you if i can forward them to my classmates and friends and aspiring nurses to give them the idea, the inspiration, the daily routine the nurse does.
Quote from angie o'plasty, rngreat idea for a thread! agree with the idea to sticky this one too!
i work for night shift for a tele unit that also takes med-surg and stroke patients, so i'm certified to read ekgs, give certain cardiac meds, and also to do the nihss (stroke scale) on appropriate patients.
i come in, get my assignment, check labs and orders from the computer, and briefly check the monitors at the desk to make sure my patients' rhythms and rates are ok. i make a note of all those with positive trops, high bnps, low electrolytes or hemoglobins, or high d-dimers with a positive ct angio, those who are npo or in prep for a procedure.
i read report and prioritize by doing a quick peek at all the patients and what's hanging on their iv. patients receiving blood or drips, or who have dyspnea, pain or who have had problems with heart rate/rhythm, and especially chest pain patients, are dealt with first.
i introduce myself, chat with the patient, get vital signs and as i roll people around in the bed to assess lung sounds and skin, i straighten their beds out and get them repositioned. i warn them if i have to come back for more vitals or if they have labs due in the wee hours--not good to frighten a heart patient.
i get the midnight meds passed and put out fires from the last shift.
as i go, i document my vitals and my initial assessment. i do a quick check through the day's orders on each patient and make sure that the correct orders have been entered into the computer.
when everyone seems to be settled down, i can take the chart and go through it more closely. is all the paperwork complete that needs to be? have all the meds been given as ordered? are all the results in the appropriate places in the chart?
critical thinking is big on night shift: why is this patient still on tele, why are we still doing accuchecks after 48 hours of no rise in blood glucose for that stroke patient, why is this new stroke patient getting dextrose in his iv fluids? why is this patient with a 3rd degree heart block not getting a pacer (because he's a 102-year-old still fighting with his family about honoring his dnr status?--yes, it's happened), who stopped the heparin drip on my pe patient an hour ago and forgot to turn the pump back on, why was the stat blood ordered for a hemoglobin of 7.3 not given (because the patient refused it, being a jehovah's). were blood cultures done on the patient whose temp shot up? oh crud, yes, but the doc never ordered the tylenol and it's 0300.
stroke patients get neuro checks every 2, 4 or per shift, depending on where they are in their course of treatment. they can't have any dextrose in iv fluids, and a temp of 99 needs to be treated.
cardiac patients get q4h vitals. ekgs are done by us along with standing chest pain orders, as appropriate. drips need to be maintained and timed blood draws need to be checked for follow-up.
in between all that, i'm giving meds, reassessing patients, changing them, helping them to use the bathroom, monitoring changes in the patient's baseline and interpreting them for significance--and helping anyone else who has a problem patient. we all help one another on night shift.
by 0600, i'd better have finished my chart checks and my written report and started to pass my 0600 meds and get everyone straightened out for day shift. the early docs are here and already writing new orders. if i have time, i'll start them, but if i don't and the orders are not stat, i can leave it for day shift (with a heads-up that they're there.)
if i'm lucky, i clock out at 0715.
Oct 21, '06Home Health Registered Nurse/ Case Manager......Up at 7am, to be at the office by 8am. Receive my assignment for the day. Gather any supplies I will need for the day, order any supplies that need to be delivered to the patients home. Pre write any lab work requisitions that I need for the day. Call the patients and plan the time I will be there. Usuall see 3 in am, 3 in afternoon. Usually in the home 40-50 minutes ( no less than 30 minute visits allowed), which I could never do because you can teach teach teach until the cows come home! Finish my day obtaining all labs results, calling the doc's about their patients if needed and and new orders. Some nurses at certain offices love updates on their patients, I think thats awesome. Will sometimes have 5 patients if more travel is needed, or less if oasis needs done. Paperwork is always complete by 5pm day of, never start a new day with old baggage. Always have time for coffee and a ear, which is what many patients need.
Oct 22, '06Quote from armsof course you can! i'm glad i could help.t'was really great reading your message. may i ask permission from you if i can forward them to my classmates and friends and aspiring nurses to give them the idea, the inspiration, the daily routine the nurse does.
Oct 22, '06New psychiatric nurse here. =) Old Med/Surge nurse, but a typical night shift in my Med/Surge job has already been eloquently described here.
So here's my night. Arrive on the unit at 2300, go listen to taped report and take notes, then hit the nurse's station and meet up with the off-going RN to round on all of the patients. Typically when we round we make a head count to make sure all the patients are accounted for, and just make sure that they are all OK and alive and breathing, and that they don't need anything at that time.
If they are awake and have anything medically going on, such as a wound dressing, or pedal edema, or pneumonia or anything, we'll assess that, but if they are sleeping soundly with no problems, we don't wake them.
After rounds, I make out the assignment sheet. I'm always the only RN on the unit, so I'm in charge of assigning, usually 4-5 MHT's to various duties. Usually I have an LPN as well but the LPN is generally fully aware of their necessary duties, unless I have an agency LPN who has never worked the unit. Anyway, I assign MHT's to which patients they will be responsible for gathering various data on through the night, I assign them each to various duties such as cleaning the kitchen, stuffing the charts, doing paperwork, emptying the trash cans on the unit, and accompaning patients to their lab draws in the early AM. Plus, I schedule each MHT to take the "board" at various times during the night. Each MHT, for one hour at a time, will do all of the 7.5 and 15 minute checks on all of the patients that are on more frequent safety checks; all other patients are checked on q30 minutes. Also if we have any patients who are on 1:1 monitoring, I will assign each MHT to sit with that patient for one hour at a time, provided that there isn't any restrictions on which sex can sit with that patient. Like, sometimes we have male patients who may be so sexually agressive that only males can sit with the patient. Just to name an example. That kind of situation kinda tends to complicate things.
After I get finished doing the assignment sheet, I then start the 24 hour report. It's basically a written, ongoing summary of the most acute patients on the floor, and how they are doing in general, over a 24 hour period. It usually includes any PRN meds that those patients have received, any behavioral incidents, any significant problems with those patients at all. Then I begin charting on each patient. We still do paper charting, and so each patient has their own sheet that is kept for 24 hours, with different checkboxes and then a place to do focus charting.
IF I don't have an LPN for the night, then around the beginning of the shift I also have to do chart checks; check for new MD orders and make sure that any new orders for the day have been checked off. I have to run controls on the glucometer, check the crash cart, check the "emergency box" and make sure that it is locked, check all of the refrigerators, check the eMAR's (we do have EMAR, even though no computer charting) and make sure that all new med orders are verified, and lessee, what else... I will have to have counted with the offgoing LPN, and of course give any scheduled meds and treatments during the night, any PRN meds, finger sticks, and then count in the AM with the oncoming LPN.
If I HAVE an LPN then I don't have to do any of the above, but of course I'm still responsible for making sure it's all done.
Then additional duties are... of course, supervising the staff and making sure they are doing their assigned duties. I have a pretty good staff on my shift and so I typically don't have too many problems, but some times my staff can get too loud at night and I have to "shush" them and remind them that patients are sleeping... and in psych, often there are patients that you *DO NOT* want to wake up! Plus, sometimes there are other problems such as.. well, we have Internet access, and sometimes I have to uh, "redirect" an MHT who is spending a bit too much time on the Web. I don't forbid it if someone wants to get on the 'net for a few minutes or whatever when we aren't busy, but some want to sit there for a long time.
Plus, I have to do treatment plan reviews. Basically go over a patient's chart periodically and see how they are doing, how they are behaving, assess how their treatment is working... see if they have any medical problems. Assess to see if they have had any abnormal vital signs... assess how well they are doing their own ADL's... how well they are eating and sleeping... and then write all of that up. I typically will do at least two of these a night, though some nights I don't have time to do any, and some nights I'm lucky and find that they are actually all updated!
There's other paperwork too. Psych nursing tends to be a LOT of paperwork, especially when you work nights. Most times if a patient is being discharged the next day, AND I'm pretty familiar with the patient, I will write up their discharge summary.
At around 4:30, I round on the patients again and again, make sure they are all accounted for and all alive and breathing and OK.
Around 5 o clock I fax my 24 hour report to the house supervisor, and finish up my charting on all patients. Around 6am I go tape report. Then between about 6:15-7:00, I chart I+O on each patient (mainly just if they urinated or not, and if they had a BM or not), chart how many hours they slept, chart any PRN meds each patient received during the night, chart any treatments done, chart if they gave blood for labs or if they refused, and chart their accu-checks, if they had any. Then at 7am after day shift has listened to my report and arrived on the unit, and someone has rounded on all the patients and made sure that they are all present and OK... I go home!
Actually a *pretty* easy job about 70 percent of the time, but it has it's stressful moments as well. Sometimes patients act up and require locked seclusion or restraining... sometimes we even have to call a "Code 500", basically meaning that the patient is SO out of control, all of the staff on the unit AND the security personnel can't handle them, so we have to have help from all available personnel in the building. That is very stressful. The event in and of itself tends to be stressful, and then all of the paperwork and assessing after the event is stressful. Then there is the fact that I alone am responsible for 27 people... my staff and the patients. I am responsible for making sure my staff does their duties and DOESN'T do things that they aren't supposed to do... and then I'm legally responsible for those 22 patients (all that our unit holds).
Overall though, it's not too bad. :hatparty:Last edit by NurseCard on Oct 22, '06
Dec 24, '06I take attendance, I try to fill any gaps. I try to figure out which way the wind is blowing and what the right answer is today, should my boss ask me anything. One day, the answer is yes, the next the wind has changed and it's no, you see. I check staffing for the following shift and try to fill gaps and see if I need to cancel anyone in a few hours.
I make rounds throughout the facility, I deal with crises, I deal with boredom between crises, I relieve people for lunch, deal with irate visitors and put out lots of fires. I help with patient care, pass meds, change dressings, basically do whatever I can to help whoever needs it, keep an eye on patients who are of particular concern. I go to any required meetings or inservices, I do evaluations, coachings, counselings, and write-up's, and that is my day.
Dec 24, '06I just transferred to a cardiovascular thoracic recovery unit and I have two more weeks of orientation. I get report on my first patient. CABG x 4, bilateral EVH 2 hours postop. I mark down my med times, check labs, post my EKG strip. Go to see my patient and straighten out the mess of lines. Shoot a CI. It's greater then 2.5 so I start to wean the dobutamine. Start to wean from the ventilator. He's a little dry so I give 500 mL 5% albumin. I take off the orders, check the med sheets, give meds. Then he has 100 mL/hr x 2 out of his chest tubes. I stop weaning, send some coags. Everything is ok, bleeding slows down. Resume weaning. I'm supposed to pick up another patient at 2200 but since my patient is still vented my preceptor picks him up for me. I continue to wean the dobutamine. By 0000 he is off the dobutamine and extubated. Missed the 6 hour mark because of that bleeding. Had to start him on some levo because he's dilated.
I take my lunch break and upon my return I pick up my second patient. AAA repair. Low BP and low urine output, my preceptor had given 500 mL LR bolus. He has a boatload of comorbidities but is doing well. BP comes up nicely. Urine output continues to be about 30 mL/hr. I do 0400 assessments, weights, labs on both patients. Give meds. My CABG patient is being paced because he was afib preop and is on an amio gtt. I pause the pacer, sinus rhythm 70s. I turn it off, shoot a CI half an hour later. CI is 2.1 so I turn it back on. Physicians are in at about 0630, I give updates and they write orders. Both may be able to transfer later in the afternoon but may stay another day. The AAA repair will be happy that he will get a cup of ice chips. I give report and finish some charting.
It was a pleasant night of work, but the thought of being on my own scares me!Last edit by incublissRN on Dec 24, '06
Dec 25, '06I get on at 6 am, get report, and go assess my patients and give morning insulins. By the time I’ve done that, the labs have come back, so I check those and chart my am assessments. Hopefully I’ve finished my charting by the time the docs come in, and I mention anything pertinent. Then I help the docs with dressing changes, give my 9 am meds, and give pain meds. Then it’s more insulin before lunch, and usually one or two discharges and admissions thrown in there. In the afternoon, more meds, especially IV abx, pain meds, nausea meds, cough meds, etc. Then before-dinner insulin, more IV abx, get everything I need from the doc before he leaves, and empty all Foleys and finish up charting and I&Os. Then give report to night shift, and go home.
I will point out that this is an ideal day. Some days I get two admits before 8 am, plus a baby on q2hr vitals, plus three IVs that go bad at once (why, oh WHY do the extremely hard sticks always pull their IVs out??), etc., etc., and I don’t even start charting on anyone until after 7 pm. But those days don’t happen all the time, for which I’m incredibly grateful.Last edit by arizonanurse on Dec 25, '06
Dec 25, '06Research Nurse: I arrive at my office at between 08:30 and 09:00. Firstly I check my emails and the answerrphone to see if any of my patients their relatives or doctors have rung overnight. There is always the chance that one of them has had an adverse event that will give me a lot of paperwork.
By 09:15 I am heading to the emergency department and emergency medical unit to see if any patients have been admitted with the diagnosis of stroke overnight. I am running a study where I need to catch patients on anti-hypertensives before they take their medication and recruit them into a study. Following this I go to the stroke unit to screen patients for another study - a secondary prevention study. If my bleep has not yet gone off, I then head to medical out-patients to our rapid access clinic to screen more patients. I speak to patients about the various research studies I am running and see if they will consent to participate.
On some days I run my own research follow-up clinic. I see patients, assess their medical health and chart all the findings in their medical notes and clinical research files.
At lunch time I run a teaching session on research methodology and then in the afternoon catch up with my administration before going on the doctor's ward round to recruit more patients.
I finish the day between 6pm and 7pm by doing admin, writing a protocol for a study or putting applications in to ethics committees or ensuring I balance the books on each research study.
I go home to my little flat, cook a light meal and watch TV and drink a glass of red wine (for medicinal purposes) before telephoning my husband and children. If it's a friday, I travel the 300 miles home to see them - oh how I wish I could find work closer to home...
Dec 25, '062330 to 0730 Palliative care here, 9 patients.
Get to the residence about 2315 if I've been off a few nights, five or ten minutes later if I'm on a stretch. If it's been a quiet evening, I chat with the evening nurses as we wait for my partner to come in. If it's been quiet, they've done the narcotic count already, other wise I do it with one of them.
Other nurse comes in, we get a quick report which often turns into a chatting session. That's the fun part of working in an environment like that.
We chase off the evening nurses (two of them) by 2345 and start our rounds. We don't do patient assignments on nights because we work together on the 9 patients. Starting at the end of the hall, we check patient status, syringe drivers, which beds are on rotation, if O2 prongs are where they should be (on the patient's face), turn out lights, check outside doors, etc.
Occasionally, we'll find a patient who has been incontinent or who is very uncomfortable and needs cleaning and positioningm or is in pain and needs a breakthrough. Otherwise we do our darndest not to waken anyone. I round every hour or so, other nurses have other schedules.
Back to the desk and then it really depends on the night. We can have a very quiet night, like last night, when all patients slept (rare), we can have a constant night when we are not running, but there is something to do at all times: giving prn breakthroughs, managing respiratory crisis or pain crisis, calling family because a pt's status has changed and we feel that they shoudl come in, calling family because a patient has passed, or we are called to a room by a family member because their loved one has passed, and on and on.
If it's a crazy night, we run until we can't any more and by then, the day staff has arrived (three of them).
We don't have treatments or anything like that, it's supportive and comfort care. But we do often sit and talk with a patient who can't sleep, or a family member who is overwhelmed by the whole dying process.
We are responsible for the chart paperwork, reordering of patient meds on Sundays and Thursdays. Charting is usually quick as we have flow charts for the most stable patients.
If a patient dies in the middle of the night, we clean up him or her, but we don't call the dr for pronouncement until day time. We do make exceptions for religions or cultures that require immediate pronouncement, otherwise, there's no rush. Families are welcome to stay as long as they want.
For breaks, we don't technically get one since there are only two of us and if we are busy, we can't leave one person alone. But, most nights, we manage to squeeze in an hour nap on the couch at the end of the hall. When it's really quiet, we treat ourselves to longer. I always let my RNA go first because I feel if all heck breaks loose and one of us doesn't get a break, I'd rather it be me since I get paid a bit of a differntial because of the missed break, but she doesn't.
And then we go home only to return 18 hours later to start all over again.Last edit by clemmm78 on Dec 25, '06 : Reason: clarification
Dec 25, '06Postpartum mother/baby nurse here; 11am - 1130pm:
Get to work at 10:35, drive around parking garage for 10 minutes trying to find a spot. Get to the floor by 10:45 or 10:50. Look at the assignement, get a general feel for the day. Say hi, get an assignment sheet, punch in, find Kardexes and get report on my patients for the day (usually 4 couplets, sometimes 5). Check charts for new orders, sign charts, pathways etc. Check printer to see if any new orders have come over.
Organize assignment sheet. Its broken down into hours. Plug in assesments, vital signs, when meds are due, and anything else.
Make first rounds: See the most recently delivered or most acute pt first, do physical assessments on mom and baby, and vs on baby. Continue thru the list of pts and their babies.
Recheck charts and printer for new orders. Read thru most recent MD notes. Look up any necessary labs, call docs if appropriate.
Second rounds are at 1600.
Third rounds are at 2000.
It sounds easy. BUT....
In between....give meds, hang IV's, monitor those w/ bp issues (pts on mag get HOURLY vs, assessments, and reflex checks) A/P pts get fetal heart tones q4h (where's the doppler?), d/c saline locks, measure voids, ambulate pts. Monitor babies for jaunidce, feeds, diaper changes, answer LOTS of questions, teach LOTS of stuff. Give baby first baths as needed. Pain meds, colace, simethicone.....Lunch break before 1830 when the cafeteria closes, wolf food down between call lights. Deal with residents, measure I/O...take new admissions:
Vag admission: Vs and assessments on mom and baby. Teach unit safety protocols, obtain self-medicaitons, teach self-medication protocol, give paperwork, check baby's band to mom's, help mom ambulate first time after epidural. Then Q4 assements and vs for mom and baby.
C-sect admission: VS q 30min X2, q1h X2, q2h X2, and then Q4hX 48. And respirations HOURLY until 12h past the time the duramorph was given in the spinal. Assessments, teaching and paperwork as above, minus the self-medications. Medicate prn, usually at least one time of phenergan, two times of nubain. Ambulate within 6h of surgery, monitor and empty foley. etc etc. Watch baby carefully, prone to temp drops after spending the day in OR with mom. VS and assessment q4h on babies.
Oh yeah, and take off the orders since there is not always a secretary. Or when there is a secretary sometimes it is one who is not as careful as they could be and its easier and safer if I just do them. (I did try the option of educating the secretary once. Once.)
When I am lucky there is a tech that wants to help out more than just the standard q4 vs on moms. Sometimes I can get one to help out with some of the many many vitals on c-sects. But they don't do anything else clinical for the most part.
So its busy. Where there are five couplets, or when there is an antepartum or a pt on mag...yeah it gets REALLY busy. Or when you have a c-sect on hourly respirs, a new vag, and a pt who is either high risk or a surgical patient that landed on the floor since they are too filled up on the normal surgical floors. Or an a/p who is in for something totally not related to her pregnancy and no one on our floor remembers how to put an NG tube in anymore, and its a non-issue since we don'thave suction anyway.
By 2300, on an ideal night, my kardexes are updated and ready to give report for the next shift. In reality, its sometimes 2315 and I am giving report without updating.