Am I taking too much time before I see pts? HELP!

KeechieSan · Oct 3, 2007

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 · Oct 4, 2007

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".

sabrn2006 · Oct 6, 2007

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

mrod, LPN, LVN · Oct 7, 2007

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 :wink2:

RN1989 · Oct 7, 2007

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 · Oct 7, 2007

Wow, thank you so much for the advice.
I will get this and thanks again :wink2:

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 · Oct 7, 2007

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 · Oct 9, 2007

RN1989 covered the bases in an awesome way :smokin: . 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, ASN, RN · Oct 11, 2007

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

nurseforHisglory · Oct 11, 2007

:welcome:

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".

Virgo_RN, BSN, RN · Oct 27, 2007

I agree it sounds like an issue of transition from student to working professional. I happen to be in both situations as I'm working as an LPN and in my second year of nursing school. I wear two different hats depending upon whether I'm working or a student.

As a student, I have to know every little detail of that patient's medical history, their primary diagnosis, every lab, every procedure, every treatment, every med, etc. I spend hours researching the patient and composing my paperwork for the next clinical day.

As a nurse, I cannot function that way and be efficient. With four patients, I'd spend my entire eight hour shift researching them instead of being at the bedside.

I do gather the same info, but not in as great of depth. Generally I want to skim the H&P to see what brought them in, any pertinent medical history, the doctor's impression and plan for treatment. I absolutely want to know their code status from the get-go. Things happen at change of shift, and I don't want to be caught unprepared. I skim the progress notes and order sheet to see what's been happening with the patient's treatment in the last 24 hours, and get a sense of what direction the doctor is going in with their treatment. I go into the electronic record and look up pertinent labs and imaging results, check to see if any are scheduled on my shift and if there are any orders dependent upon those results. I want to know their last set of vitals, when their next meds are due, and any meds that are timed, such as cardiac meds or antibiotics. If they have pain, I want to know when their last pain med was and what it was. I want to know if they have a peripheral IV or a central line, and if they have any drips. I also check the worklist to see if there are any nursing actions I need to be aware of, such as orders for ambulation, fluid restrictions, post void residuals, etc.

Basically I do a once over on their chart, both paper and electronic, to see if there is anything that I need to do sooner rather than later. I have more than once been bitten in the behind by relying on report from the off going shift, having not been told important details only to find them on the worklist or elsewhere in the chart but too late in my shift to be able to catch up and do anything about it. I once found medication orders that had been written in the morning and not scanned into the system by the time I got there in the afternoon. "I haven't had time to look at the chart" is a lame excuse for not knowing important things about your patient or their care.

When I get report from the off going shift, I don't need the last set of vitals; I can look them up. I don't need lab values; I can look them up. I don't need to know the diet order or activity level or really much of anything; I can look everything up. What I do need to know is what is the patient's general condition, have there been any changes in the patient's condition, is the doctor aware of the patient's condition, and what is the plan for the next 24 hours or so? Have there been any events that I should know about? Does the off going nurse have any sense of anything that I might keep an eye out for (like patients who seem alert and oriented but may sundown on my shift, or patients who may start withdrawing from alcohol within the next twenty four hours). Are there any family members with concerns that I can help with? Stuff like that is what I need to hear about from the previous shift.

Everything else I can look up myself. I'm not comfortable taking someone's word that a patient's trops were normal, without seeing that lab result with my own eyes. If I have to call the doctor for any change in the patient's condition, I want to have directly observed the relevant data for myself, rather than lamely saying "Well, day shift said....." without having actually laid eyes on that for myself. Now granted, if I ever do call the doc, I have the chart right there so I can answer any questions he or she might have. But that's lot easier to do if I've already reviewed everything at the start of my shift and have a good sense of what's going on from the beginning.

It's not really that time consuming once you get the hang of it. I made my own worksheet that is set up in such a way that I can quickly look up pertinent info and note it on the worksheet so I have it with me. If I have four patients, which is average, I can gather all this info on all four patients and be at the bedside starting vitals and assessments about a half hour after the beginning of my shift, depending on how long it takes to get report from the off going shift (some are more long-winded than others). I don't really care if the previous nurse thought breath sounds were decreased or they heard crackles. I will be observing that for myself, and often my observations are different from what the previous nurse documented (sometimes I wonder if anyone's actually been assessing or if they're just charting what they got in report). By gathering information for myself, I already know a lot about them when I walk in that room, so I can do a more focused assessment and be more efficient that way.

I think it's a critical step to gather information before beginning rounds on my patients, but once I have the info, I'm triaging the rest of my night. I look at what meds really need to be given at a specific time, what procedures really need to get done on my shift, and what's not going to hurt if I have to pass it on. I don't plan on passing on work to the next shift and I don't like to do it, but I have to prioritize, and sometimes things just have to get passed on. I just try to make sure they are going to be the least inconvenient for the next shift, and I feel I'm doing them a favor if I give them a heads up in report that something didn't get done instead of letting them discover it on their own in the middle of their own shift. The way I see it, patient care is a team effort and we have to support each other instead of giving each other flak.

On a busy night, I might have to stay a half hour late catching up on my documentation. If I gave up my breaks, I could get out on time, but I'm not willing to do that. I've only been nursing for a few months, and I learn something every single night. And every single morning, when I wake up, I remember something I forgot the night before. But for being so new, I think I'm doing pretty good, and I think you can too. The most valuable advice I got during my orientation is that I need to triage. I'm triaging my patient care. I cannot possibly do everything every single shift, and I have to prioritize what is the most important, what absolutely has to get done at a specific time, and the rest can either get done or not. On my worksheet I have boxes for every hour of my shift, and if there is something that needs to happen at a certain time, I write it in the appropriate box.

I hope I've been helpful. I think organization and time management are probably the toughest things for new grads, and getting used to the feeling that you're always one step behind. I look forward to the day when I am always one step ahead, but I think that is something that comes with time and experience.