What are your routines like on a medsurg unit - page 2
I wanted to know what your routines are on a med surg unit. When we are doing clinical rotations as students we do everything from epyting bed pans to checking line and giving meds . Now I am... Read More
Apr 21, '04Quote from RN-PAThis was very complete report I am coping all these replies and keeping them with me as a reminder as to how to work on the unit. It already has helped since I took your advice I set up my drawers with all the 10 oclock meds in a med cup and I put Ns syringes for IV flushes. Like you suggested I come in the morning early so I can see the assignments and start looking at the charts and try to supply the med cart so I am ready after report. I love reading these post they have been the most helpful to me this semester. I still need lots of improvement. This weekend I will work with a different preceptor so I want to show her how much I have learned and I hope I am a real help to her. i want to work onthis unit . Thanks againI work med-surg 3-11 (1445-2315) shift, and I'm always looking for ways to use my time well. If the 7-3 nurse is late in giving me report at the beginning of my shift, I'll start checking charts and/or going through the medication kardexes and begin writing down when all my meds are due. If I see that patients have INT's (heplocks) or PICC lines, I may begin filling syringes with NSS and putting them in their med drawers while I'm waiting. I work part-time, so I rarely get the same patient assignment 2 nights in a row, so I'm frequently "starting from scratch" each time I work. If you get the same patients a few days in a row, it'll help you because you'll know how best to organize yourself-- when the most meds are due, when a patient prefers his wound care, this patient needs his heparin gtt renewed daily, etc.
After report, I do quick chart checks on my 4-6 patients (if I only have 4 patients, I will usually have at least one more patient assigned-- admission, post-op, or transfer before I'm out of report, and a total of 6 by the end of the shift.) I then go through all the med kardexes and write out when meds are due in columns from 1600 to 2200. (I just write room # and "PO X 5", "SQ Hep", "IV Ancef or IV Lev"-- abbreviations to give me an idea of what's due) I gather any 1600 meds, and will see either a patient who has an IV piggyback med due or the patient(s) with highest acuity first, as others have mentioned. Since dinner comes at 1700, I try to get as many assessments done between 1600 and 1700. If I have an NPO or tube-feeding patient, (and they're stable), I leave their assessments for last. If I'm REALLY swamped, I say hello to patients whose dinner's arrived and promise to assess them when they're done (after asking if they need anything). At some point in this first hour, I give a quick report to the PCT I'm working with and will delegate anything I can to her at that time. I check over the vital signs and write the temps and BP's on my report sheet, as well as accuchecks of all my patients if she's obtained them by that time.
As you get an assessment routine down and become more comfortable, you will learn to do two-three things at once. While you're assessing their orientation, you can be checking pedal pulses and edema; as I'm introducing myself, I'm checking their IV fluids and their IV site, maybe hanging an IV med. Listen to heart, bowel sounds, lungs (check sacrum and skin while they're lying on their side), check incisions, wounds, etc. Check urine output, remind patient to use urinal or "hat" if on I&O, ask about pain/nausea/SOB/DOE. Check O2 and do a pulse ox. I write my ABNORMAL findings only on the back of my report sheet and will document them on the computer when I have time (sometimes that's at 2330 or midnight...) With 8 patients, you'll have to do more focused-type assessments as others have mentioned, to save time. If I have a chatty patient, or as I'm doing teaching, I'll tidy up their room-- fold a blanket, throw away excess cups, take out their leftover lunch tray, make a neat stack of newspapers. This is ONLY if I'm not crazy-busy at the beginning of a shift (rare), but I'll neaten up at some point during the shift.
I sometimes combine 1600 and 1700 meds if it's really busy (and depending on what the meds are), and I'm always trying to combine trips to the med room and save time by making a mental list or quickly scribbling all the things I need to save a trip: 302-1-- juice. 304-1-- Percocet & denture cup. 305-2-- IV Ancef/IV Flagyl. I also make a list of things I need to remember to do at the bottom of the sheet where I have my meds and times due listed like: 310-1--PTT at 1800/Coumadin order. 310-1-- sleeper (means I need to order a sleeping pill when house doc comes on at 1900) 308-1 check pulse ox at 1900. 308-2-- pre-op teaching.
I keep a list on my clipboard of frequently called extensions so I don't waste time looking for phone numbers. And all I've mentioned is just a basic "structure" for my routine. It all goes out the window, of course, when you're calling docs for problems and orders, hanging blood products, helping the LPN with her needs, walking people to the bathroom, running for pain meds, taking report from PACU on your post-op or from the GI lab about your patient's colonoscopy, talking to family members, taking off orders, etc. etc. etc.
May 6, '04I work nights and generally have 6-8 patients per shift. We give written reports, but also sit with the person relieving us to go over it verbally in case they have any questions or can't read the handwriting.
Following report, I begin my assessments, starting with the more serious ones & fresh post-op ones first. Sometimes, I will have to see someone who doesn't really fall into this category earlier on because of calling for pain meds, IVFs finsished, PCA needing new syringe, etc.
There's a lock box in the wall outside each patients' door that contains their MAR, PCP & non-controlled meds. I read over the MAR & PCP for that patient before going into their room and take along any meds that may be due around that time. Reading each MAR & PCP before seeing that patient helps not to confuse one patient with another.
I generally do a head-to-toe assessment on each patient. I'll start with introducing myself and while "chatting" with the patient during my assessment, I pick up info the patient doesn't realize they're giving about how alert & oriented they are and much more. After the introduction, I begin by listening to their heart & breath sounds. While doing this, I can look over their body for any tubes, IV sites, etc. the previous nurse may have forgotten to tell me about and also see if it's working properly. I can also glance at how much fluid is left in IV bags, giving me an idea of about how much longer I can expect to change it. After this, I usually flush any INTs, but may wait until I finish the rest of the assessment. If it is a patient who's had neuro surgery (or anyone else who may need it), I check PERRLA and strength in all 4 extremities. If it is a surgical patient, I ALWAYS check the dressings...I've heard some stories about patients with back surgery laying in a pool of blood & no one bothered to turn them over to check the dressing until it was too late. I then do neurovascular checks on the limbs of what was operated on...if cervical or spinal, I'll check both limbs, especially pedal...if breast reduction, I'll check both arms & radial pulses.
After I do the assessments, I'll chart them in the computer. Then, it's time to check off the MARs for the next day. I have to keep up with the time during all this because meds are ordered at all kinds of times. When I finish charting & checking MARs, I then go around to the rooms to put the new MARs & PCPs in the patients' lock boxes for the next shift. During this time, I peek in at the patients as I pass their rooms.
By the time all of the above is done, it's about 2 hours before the end of the shift & I can SOMETIMES finally visit the bathroom and grab another cup of coffee & start writing report for the next shift. The last hour is pretty hectic with catching up with the techs to find out the BMGs, weights, and other things they're supposed to have done; checking the computer for the vitals and I&Os the techs checked and recorded; giving insulin or any other meds needed; D/Cing any drains ordered; and more.
All of the above sounds like it may be easy flowing, but keep in mind that the patients don't think about their nurse having a routine. They call all during this time needing something...or confused ones trying to get out of bed if they aren't supposed to. Then, there's the dressing changes that are (yes, even in the middle of the night) to be done. The blood to be hung. Machines beeping that need something changed or fixed. And more.
May 7, '04SCRN1- I too want to work the night shift. Your routine sounds very organized. I may print it out.
May 7, '04LOL, it may LOOK organized, but things don't always go as PLANNED if you know what I mean. One of the advantages to working nights is that there aren't as many people (MDs, PT, students, etc.) needing the same chart you need at the same time. Also, I can be home during the day if I have a child out sick from school and when they're out of school for holidays & summer. May have to sleep, but I'm there if they need me. Mine are old enough to be alone...13 & 16. Good luck with everything.
May 7, '04The first thing I do (because report is almost always late), is check the MARs. This way I know to check and ask about any unusual med or combination of meds. Then I look at the patient's hx because many times that is forgotten in report. This gives me a general idea of what may come up such as when a person converts to A fib and they have a hx- I know this is not something new to the patient even though I will address this issue. Another thing is I will know to question why a CHF or renal patient is having an IV running at 150 cc/hr. This helps to prevent problems from occuring.
I also do a focused assesment and leave blank areas I have not addressed such as skin integrity, urine, stool- ect. Later when I have more time I will be able to turn the patient over to check for pressure ulcers and if they are using the commode I can check the appearance of their urine and stool. I then chart these.
I know alot of nurses chart full assesments- many using the previous shifts assesment to fill in what they have not checked. Even when time is limited it is best not to do this- so please don't be tempted. I recently got report on a patient who reportedly had a nasty skin tear on his left arm. For 5 shifts it was reported on his left arm. It was really on his right hand with the left arm being clear. Better to leave the skin integrity blank then to chart something you have not seen. Good luck on med-surg.
May 26, '04First of all, thank the Lord I live in MN, home of fully-staffed hospitals. One of my teachers told me "plan for at least one unexpected thing that'll take up at least 30-45 minutes of your time". Someone needs a transfusion, someone's lumbar drain falls out (that was a fun one), someone's BP goes downhill, new admit, someone's family is asking you six-dozen questions, someone has unexpected chest pain, someone gets confused and yanks out their foley and IV, someone needs to be straight-cathed and turns out they have a "hidden urethra", etc...Always do your most important stuff first as everyone has said so that you have at least the basics done before something "hits the fan"....
Feb 15, '05I'm a senior nursing student, and these examples are great for helping me get organized. It's true that you get your own routine, but it's much faster to get a personal routine if there are good examples to take parts from. Thanks, everyone, for sharing. It's priceless information for us newbies.