Assessments, meds, documentation - need some tips

Mavnurse17, BSN, RN · Jun 25, 2019

Hi! I left the bedside almost a year ago, but hopefully this might guide you a little. I worked on a very busy cardiac PCU, taking 3-4 patients a night.

What really helped me was coming in a little earlier to start looking up my patients, their diagnoses, meds, recent notes, etc., so I had a basic idea of what I'd be walking into. Are you able to do this at your clinical hospital? It will help.

Start by seeing your most critical/sickest patient first. If all of your patients are relatively stable, start with the patient that you anticipate will need the most nursing care. (I should note here that my hospital utilized bedside report, so I was able to at least lay eyes on my patients before I went back in later to do a head to toe assessment--this allowed me a few minutes after report to figure out how I wanted to organize my shift).

Most of the time I would see each patient one at a time and do their assessment, meds, and provide nursing care all in one sweep. This is the most efficient way of doing things imo. But some nights I wouldn't have meds to give until 2200 (could be given as early as 2100), but you can see how I wouldn't be able to save the nursing care and assessment until that late, so I'd get their assessment out of the way first and go back to give that later med after I'd seen the others. Does that make sense?

Document in the room if you can. It will be done and out of the way, plus the chance of you missing or incorrectly documenting anything will be lower.

I was just like you when I was in school and as a new grad nurse. I really struggled with time management--so much so that my preceptor would literally stand outside of the room with a timer. She gave me 15 minutes per patient to assess, give meds, and provide nursing care, which sounded like NOTHING back then. Once you start progressing in your career you'll start getting a little quicker.

Hope this helps!!

JKL33 · Jun 30, 2019

I strongly recommend that you not access any patient information prior to the official start time of your clinical, and in your future positions as an RN you won't want to access information prior to being officially on-duty, either.

You will get better at filtering the information received in report in order to quickly prioritize an order for further assessing patients as described by the previous poster.

Random stuff:

- It's possible that each element you mentioned (assessment, meds, documentation, etc.) is simply taking longer right now than it will eventually need to. For example, a basic assessment (hitting all major systems) can be accomplished rather quickly - - but not when just starting out; it takes practice to eventually learn how assessment time should be spent or saved. Maybe it would help you to start with the big picture/quick look, then a basic head-to-toe, and hone in as necessary. Don't spend time belaboring assessments that your "first look" already answered, etc. Most of all, don't be too hard on yourself. As long as you keep working on it, one day you will just randomly realize that you are going faster and becoming more efficient.

- Start to establish a routine for meeting a new patient and quickly beginning to develop a friendly rapport so that when it is time for you to accomplish a particular task (such as your assessment) you are able to comfortably do so in a purposeful manner. That is a nice way of saying that a lot of time can be spent on an assessment that is interspersed between long periods of chit-chatting (and listening to long off-topic stories...) when the nurse stops moving each time the patient says something in order to stand there and talk. This is not to say that you shouldn't get to know your patient or that what they want to say isn't important (of course it is!) - but just that one goal should be that you become comfortable explaining to the patient what you would like to do/gaining their permission, and then purposefully going about your task without a lot of interruption. ["I would like to take a couple of minutes to do my assessment now - - does that sound okay?" - - then do it and get it done. You will have time to chat a little bit afterward]. Eventually you will be able to incorporate some conversation (such as your findings) while you are assessing - - and keep moving at the same time. ?

- Don't double document. Try very hard not to document the same information in multiple spots just because there may be places for the info in different areas of your documentation tool. Find out the expected place and/or the best place and put it there.

- Don't forget that in your final semester/externship another learning objective is that of appropriate delegation. This doesn't mean you won't be doing any "nursing assistant" tasks, but that you do need to learn about developing rapports with your team members and learn to work together. In doing so, a goal should be to develop the confidence to delegate a task when there are priorities that can only be accomplished by an RN. You will also learn to know when it is most efficient to work alongside the tech/NA to complete a particular task and when to do it yourself, and the importance of helping out with any/all tasks as much as possible.

- You could inquire whether any of the RNs at your clinical site use a brain sheet/organizational tool and whether they might have a few minutes to show you how they use it.

- Overall try to consider/focus on the concept of being purposeful. Avoid the "tumbleweed" approach where you are wandering whichever way the wind happens to blow you without the ability to determine which way you are going to go. ? If you are supposed to give Mrs. S. her 0900 meds now, then do that and get it done. If your goal is to do Mr. M's assessment now, then do it and get it done. Etc. If you need to, be specific (at least for right now). Instead of, "I'm going to go see Mr. B and do all of his morning stuff," break that task down into its elements and accomplish each one.

Good luck! Don't panic. This will get much easier with just a little time and experience.

FutureRN20190 · Jun 30, 2019

Wow thank you both sooo much for taking time to provide such amazing tips!!! I really really appreciate your wisdom!!!