how to manage multiple patients on L & D

  1. I would love to see some practical, doable, time saving suggestions here. I am in high risk OB and it is hard for me to chart patient progress every 15 minutes on multiple pts receiving pitocin, assess CTX pattern, FHTs and run to rooms upping the pumps. I am thinking that I need to just make a copy of the MD orders and place them in ea room, do my initial assess and then wait until 0400 or early morning to try and get my paper charting done. (We do a mix of computer and paper charting often causing at least double but more like triple and s/t quadruple charting.) On top of this I have a student, who I am trying to keep challenged but I cannot trust to reliably do things because she is just learning. It is so stressful. Any advice? Oh I am 14 months post graduation. (And my student nurse is actually really stressing me out.)

    Thanks.
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  2. 17 Comments

  3. by   Jolie
    How many laboring patients are you caring for at a time? In the facilities where I've worked, a nurse with a pit patient would only be assigned one other STABLE patient, usually a post-partum mom (LDRP unit), or a very early laboring mom (up and walking). I can't make any practical suggestions other than to look at your nurse to patient ratio and acuity. It sounds too high to me.
  4. by   Selke
    I agree -- sounds like you have too many patients, and this is UNSAFE. I think AWHONN has standards published, and California mandates no more than 2 L&D patients, and it becomes 1:1 when second stage and PP recovery. Why are you precepting a nurse when you yourself are barely out of school?
  5. by   SpudID
    Just to clarify, we often take 2 laboring patients. That night I had 2 and then a walk in. Of the 2 I had, they were early in labor with slow progress, being induced (1 had a gastrochesis baby) and one had IUGR. The 3rd walk had 3 prenatal visits total and her due date was 1/22/07. (Her baby had little variability and nothing that met an accel). She was Spanish speaking only. I was able to give #3 away because one of my pts (the iugr baby) was having repetitive lates and they were consenting her for C/S. (The baby also had no accels.) We were understaffed that night. This is not a usual scenario but I am feeling a snowed under.

    After a pt reaches 2nd stage or just prior to, we do go down to 1:1 care.

    I am precepting a student (I later found out) because many of the staff did not like her and so I was assigned to her. We are not a very good personality fit. The new nurses are often paired with immersion students because we are a teaching hospital.

    Any suggestions to how I can get organized and how to precept a student?

    Thanks,

    Spud
  6. by   JaneyW
    You can get as organized as you want, but L&D--esp high risk--is a very unpredictable area and things change all the time. Can you lobby mangmt to change your charting so you are not repeating yourself so much? That is also very bad for legal reasons--leaves a lot of area for contradiction in charting. Do you have a student or a new grad? If it is a student, they will just have to go with the flow and realize that when things get too hairy, you won't have time for much in-depth teaching. She will have to learn by watching. If it is a new grad, she will have to step in more and do as much as possible to help you out.

    Where do you get the staff to go to 1:1 if you have no help before that? Is there a charge nurse that can be doing more so that you can focus more on your patients? I sure know when I have a busy day and a good charge nurse backing me up. That makes a huge difference. L&D is really a team effort most of the time--maybe your unit doesn't work that way efficiently?

    We recently went to all computer charting and after the initial learning curve I am finding it much easier than paper. It is faster and keeping up on charting really lowers your stress level!
  7. by   nurse79
    yea it is very difficult to have 2 pts L/d, depending on the station of their labor. But esp. being new to L/D, I also find it hard having 2 pts on pit. regardless on if they are both in early labor. I feel like i just go room to room..how do u guys manage? I too am usually one of the first to get a second pt seeing that i am new to l/d..although my staff is helpful at times with procedures (admitting, IV's, getting chart ready)..but the charting is still time consuming, EVEN with computers.
  8. by   SpudID
    THANK YOU Nurse 79. That is exactly how I feel. I am overwhelmed with two patients when they are on pit. I was also just wondering about prioritizing care. How do I get in and see each patient within 30 minutes of coming on shift?

    Spud
  9. by   Dayray
    We often have 2 labor patients and many time's newer nurses need help as well as the unforeseen things that come up.

    The best advise I can offer is to constantly keep a mental list of things that you have to do and how important each is. It's like triage you address the most important things first. When something new turns up add it to you list and reorder your priorities.

    Always try to plan it so you knock out multiple tasks in one trip. I.e.

    If one of your tasks takes you past the med room stop there grab your meds while your in the med room try to think of supplies you might need and grab them on the way to ice machine, breeze by the nurses station and then deliver your meds while your in the room if nothing else is pressing think of things you need to do there before leaving. Instead of looking at each thing as one task try to make your movements a sweep that knock out multiple task's in one trip. Picture in your mind where you will be going and what task's you can accomplish on the way to the most important one and on the way back.

    Everytime you are in room assess your patient as you are doing other things. You can ask them how they are and if they need anything while hanging/pushing meds. If you can make it so you address problems while in the room then call lights don't go off after you have left. You can easily palpate contx while asking your patient question while your other hand does something else. You must learn to do more then one thing at a time. I constantly run threw my patients needs and align priorities a good time for this is while you are walking.

    Charting is the bane of my existence. I can easily provide good care to several patients at the same time but charting hangs me quite often. I need to practice what I preach because often I don't do this but. If you are able to carry your paper charting with you or able to do computer charting at bedside. Try to chart things you have done and your Q15 or Q30 stuff in the room just safer or as you do them.

    As for your student. Her best learning is from watching you. Think of things she can do on your trip's to the room. While you are charting she can hang the meds or vise versa. Ask her questions and provide experiences for the questions she can't answer.

    Whenever you do something ask yourself what other tanks you can accomplish at the same time. I.e. check a cervix change the lines at the same time and turn the patient check her foly as you finish.

    Always make sure you are accomplishing at least 2 tings at once (did I say that already? lol). If you cant do things in one trip evaluate how important the task you are planning is and ask if it can be put off until you have another reason to go in that direction. I feel like I'm wasting time/energy if I'm not accomplishing more then one thing at a time.

    While you are swirling around make sure your patients know you are paying attention to them sit down while you talk to them. If you have extra time spend it in the room (hopefully you can watch central monitoring in rooms). Also if you can chart in the room at least you are present while you are doing this.
  10. by   SpudID
    Wow thanks. That is great. I have been grabbing a paper towel to write down things; so I can group my care but I will make it a goal to actually group my care better. I will try to make a list of priorities and then I can go down and ask them and do them while I am in the room; so I can run less. Charting is what is the killer. Can anyone refer me to a website or book that helps you chart more efficiently? I took a EFM charting course and it made me paranoid aftewards. They wanted nurses to chart everything for liability concerns. I started to do this and was actually reprimanded by my RN manager that it was too much and taking too much time.

    Thanks again!

    Spud
  11. by   MamaMadge
    When I come on, after report, checking MD orders, I always (unless of course my patient is delivering!) make a little check list of things I have to do ie. meds, assessments, things that need to be checked out, like lab results etc. Then as I do each thing I tick it off. I carry it in my pocket with all my patient's data on it. I am just too new to make a "mental note".....I will forget if it's not written down. I check that little sheet often during my shift. I also write down the provider's pager number so I have it handy if I need to call them asap.

    I think you should also check your state's nurse patient ration for Pitocin patients...also, check AWOHNN guidelines as another resource when you speak to your manager. GOOD LUCK!
  12. by   SmilingBluEyes
    I find the use of flow charts and exception charting invaluable. And like said above, you can only be "so organized". I am very organized, efficient and yes, anal----(my coworkers' description of me no less, lol)--- in my OB practices. But I have had many a shift whereby all my best-laid plans and organization went out the window. You simply cannot predict or control what presents to your unit at any time in your shift. Learning to prioritize and be organized are skills that only come with plenty of time and experience---more like 2 or 3 years in OB, not just a few months. I have about 10 years in it, and still find precepting a challenge. It really does throw off organization for me, as it's often MUCH easier to "just do things myself" than try to let a new person do them. I have to really re-think my day and organization when I am precepting new nurses and students (not that that is bad, but I am just saying, this is a challenge for anyone, particularly one with less than 2 years as an OB nurse).

    Any chance you can hold off precepting others til after you have more like 2-3 years' experience first? You really need to get your own skills and organization down first, before trying to add precepting to your duties. That is a heavy load for a new nurse to handle.

    Anyhow, I wish you all the best. Hang in there.
    Last edit by SmilingBluEyes on Feb 27, '07
  13. by   ellescorpio
    I work in a busy labor and delivery and often have to take 3 and on really bad days 4 patients. I try to chart in the same order each time so that I don't forget anything. I always write my assessments the same, age G&P's reason pt is here ex ROMNIL, GHTN, in early labor or whatever the reason my be. I then assess baby, mom's ctx, and head to toe assessment. It may sound simple but writing my notes the same each time just helps me get my charting done quickly without forgetting anything. I also multitask as suggested earlier, the more efficiently the better. I always ask my patients if everything is ok or how they are doing before I leave the room, I find it makes them feel better and saves me time from having to answer call lights. Good luck!
  14. by   htrn
    There have been some excellent suggestions already made, my only addition would be:

    I'm sorry Dr. so and so. I realize that your patient does need to be delivered, but it is not safe for me to start or continue to increase pitocin on that patient right now. I will gladly monitor her until we get another nurse to come in or my currently active patients deliver.

    We have had to do this several times. Docs will fill up our calander, then we get two or three patients that come in during the night and don't deliver before their inductions come it. Heck, if we have three labor patients, then we don't even have a bed to put an induction.

    I agree with Dayray, I can take care of more patients than I can keep up on charting for. Worse case scenario, I run in, look at the strip, initial it, chart on it quick if I did anything, then sit around for 2 hours back charting at the end of my shift.

    Your NM needs to do something about your staffing ratios - what you describe is VERY UNSAFE. Good luck - and get someone else to precept students or sit her down with your policy and procedure book.

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