Best way to prepare for 5 pts at start of 12h day?

poppy07 · Mar 17, 2009

Hey, I work in the ICU and have 2 pts usually, but we give meds a lot more often, check on our patients continuously and respond as needed continuously.

My suggestion to you is to get a game plan.

You have 5 patients?

Do you do all your assmessments first, then give out meds?

How often does it seem that you have to give out meds, and how many (to one patient)? Like one patient-meds at 8, 12, 6 or what?

So, this is what i do:

Get my assignment, go look at each patient quickly (glance in room-make sure abc's are good), then do assessment quickly but thoroughly of each, document assess. and the review meds. we pass meds usu. at 10, 12, 6 etc. some more often

then just punch out the meds quickly, and continue on with other needs

NewGradRN47 · Mar 17, 2009

I work on a pulmonary stepdown where most pts are trached or ETT on vents. I take care of 5-6 pts regularly and 7-8 when we are short staffed. When I first started, I would always leave 1-2 hrs late just catching up on documentation. Some things just take time. You have to learn where all the supplies are, what is best to delegate to who, and of course, prioritization. Especially if you are working consective days, you can learn what needs to be done today and what can be done tomorrow or what to endorse.

Anyways, here is what I do:

Get assignment

Spend 1-2 min in each room

I look at: ID bands (which colors), IV access, Any IVs going, O2 source (nasal cannula, trach, etc), Alert/Orientation, Foley, SCDs, and everything else that is visible without even touching the pt. I say hi to pt/family member and introduce myself and see if there are any pressing concerns.

Get report

Go through orders for each pt and make sure they correlate with report; Check to see if applicable DNR/DNI are in chart and correctly filled out; Document my daily assessment for 1-1.5hr with hopefully minimal interuptions

Do 1st round of meds while looking at morning set of vitals; While in the room I do a more detailed assessment since I'm already gloved (pulses, edema, lung sounds, etc)

Back to documentation

The rest of the shift: meds, cleaning pts, nrsg care (trach care, priming tube feed tubing, etc)

I write my PIE notes in the chart at around 2-3 pm.

The key here is that my big priority is documentation. Once that is out of the way nice and early, I have the rest of the shift to be a nurse. I felt like a was running around with no time if I still had to do my documentation and kept putting it off until it was 8pm and the shift was over.

What I've seen some nurses do is start meds early and give pt #1 meds and document on pt #1, go give pt #2 meds and documents on pt#2, etc. I prefer to document what I know (even if I haven't completed my detailed assessment) and go back and modify as necessary. It's imp to look at diagnosis and past medical hx to know what to look out for. For example, PMHx Afib and AM set of vital signs show HR110 and pt to receive meds at 10am, pulse is prob going to be irregular. Or pt receives breathing tx, they will prob having wheezing upon auscultation. Pt had no BM x2 days and receives colace, the bowel sounds should be diminished. So on and so on. I make these educated guesses, and when I complete my detailed assessment with meds and go back and modify as needed. (we have computerize documentation so it works well this way). Not all will agree with this, but this is how it works for me.

During my shift I have three papers. I keep them either in the report book or in a folder with my name on it:

1. The first one is my "dirty" one that I scribble down my rough assessments that I throw out once I'm done with my daily documentation in my computer. This is made within the first 15 min at work.

2. The second is the print out of my patient list where I have two columns. The first is for me, where I write down things I need to get back to sooner or later (pt needs to new IV, don't forget to complete x flowsheet, look at CXR, etc). The second column is what I need to tell the MD (d/c blood glucose monitoring q 4hr, reorder IVF, d/c NPO and reorder tube feeds, etc). I check off each phrase as I complete them or as the MD places the orders. I continually update this throughout the shift as new things occur (ie, pt NPO for PEG tomorrow, hang IVF). This is also where I give my report from to next shift since it has all the new stuff on there.

3. The third and last paper is my assignment sheet with for my nrsg techs. I keep the original for myself and make copies for the techs. Here is where i right if they are PO/PEG/NPO, Full code or DNR, blood glucose checks and the results as I get them, foley or bs commode or incontinent, isolation pt or clean, and any other pertinent info (ie no BP right arm, daily weight). I complete this hopefully by 9-10am. I like this because it's a quick overview of all the pts and help remember their names and general status.

Hope this helps!

Good luck, but don't stress!

litbitblack, ASN, RN · Mar 17, 2009

What i used to do was document my assessment in the room with the pt. Here goes.

get assignment and report

check mar and review charts to see whats due

any 730 meds or insulins go ahead and take care

while i am giving those i go ahead and assess that pt. You would be amazed at what you assess by talking for a few minutes. it just takes some practice

so after thats done i go ahead and see my other pts and if its 830 take them their meds that are due at 8 (unless before meals or take byself) and meds that are due at 9 as you have 1/2 hour before and after they are due so this works.

i then go and document everything else i need to and plan the rest of my day. wound care, central line dressings, helping other nurses on the floor. Try to get a system that works for you. combine stuff. you can change that central line drsg when you are giving them there morning meds and doing the assessment. change sheets while waiting for them to get out of bathroom.

A question though

why don't you have a unit sec and why are the nurses transferring the pts to test. Do the dept not have employees to take the pts. I would definately be looking at that and if its something that is usual for that place i might not want to stay there. you have to have ancillary staff to make it work

Vito Andolini · Mar 17, 2009

If the meds are only daily, it's ok to give them a little late. Not every pill has to be given at 0800. They can even be given on a different shift if all staff agree and you get the appropriate order.

Are you spending lots of time donning and removing isolation gear? That can be very time-consuming. Really get organized and try to do everything for these patients at once, if possible, so you are not having to go in and out of the room more than a couple of times per shift. Hopefully, you can see them through a glass to make sure they're alive, have not fallen, etc. Or maybe it's not necessary to put all the gear on if you're just going to be looking at them. Just mask and gloves maybe?

As for ICU vs. the floor - ICU requires a lot less running up and down the hall, obviously.

STOP DOING THE TECHS' WORK. STOP DOING THE TECHS' WORK. OH, AND DID I SAY IT? STOP DOING THE TECHS' WORK.

**canoehead, BSN, RN** · Mar 17, 2009

I prefer to document what I know (even if I haven't completed my detailed assessment) and go back and modify as necessary. It's imp to look at diagnosis and past medical hx to know what to look out for. For example, PMHx Afib and AM set of vital signs show HR110 and pt to receive meds at 10am, pulse is prob going to be irregular. Or pt receives breathing tx, they will prob having wheezing upon auscultation. Pt had no BM x2 days and receives colace, the bowel sounds should be diminished. So on and so on. I make these educated guesses, and when I complete my detailed assessment with meds and go back and modify as needed. (we have computerize documentation so it works well this way). Not all will agree with this, but this is how it works for me.

I don't recommend this. You will wind up documenting things you didn't actually check, or writing down an assessment that is incorrect or has changed. You will also get an unreliable reputation if you sit down and fill in all your assessment data before ever going into a patient room. There is a bias to see and hear what we expect rather than what's there, even if we try to avoid it. And what about the patient that changes within the 2-3 hours between assessments? Or the emergency that happens between the documentation and the actual assessment (so you actually don't get to lay hands on the patient). Even with good intentions I think this is falsifying a chart.

For floor patients in the ER I get a look at them from the door after report, then go look at my sickest patient first. I try to bundle the care, meds, assessment , wash, pee, and bring all my supplies and linen with the morning check. Usually I take 20 minutes per patient, and come out of each room with a to-do list for the day. I'll document after each person if things aren't crazy, or at least write vitals. I find making 3 trips for meds, assessment, and bath makes me feel fragmented, and wastes trips up and down the hall.

DroogieRN · Mar 17, 2009

As someone getting ready to start my second year of an RN program, I really benefit from threads like these. However, they also scare me -- I can't imagine being able to get it all done. Plus, my hospital is getting ready to get rid of all techs/aides and make nurse:pt ratios 5:1 with the RNs responsible for everything the techs/aides do now. I just don't see how that will work out well for the nurses or the patients...

interleukin · Mar 17, 2009

There is no way humanly possible to handle this kind of workload considering the unpredictable nature of nursing and the continuing "grandfathering" and yet more indirect nursing tasks and duties.

At my first job at VA, I had as many as 14 patients! It was out of control but no seemed to care.

I can't imagine going back to a floor. ER/ICU's the only way to go. I think many more nurses would do it except they think it's "too complicated or too scary. "

IMO, considering their responsibility, I think floor nurses have the hardest job on the planet. And how you can balance the enormity of tasks and not feel like you're just a blue-collar monkey is beyond me.

FLOOR NURSES ARE AMAZING!

flygirl43 · Mar 17, 2009

1) Assessments with am care....get to really know them 2) Meds and blood sugars 3) Blood work 4) Delegate) Anything that can wait, will wait....if they don't get washed until 3pm....they still got washed (5) Prioritize and get you game plan down. I find I finish way before other nurses, but I am an anal organizer, and if they don't crash or code, my game plan usually works

flygirl43 · Mar 17, 2009

Had 13 pts last hs...all very acute and on telemetry....chest pain....anyphylactic reactions.....blah blah blah. I survived and so did they. It takes time to plan your game. Just think about it and figure out your priorities

mama_d, BSN, RN · Mar 17, 2009

I work tele on nights, and our ratio is 5-6:1. I've done days with the same ratio, I know how hectic it can get. At least on nights we have the benefit of less docs, less ancillary departments, and less testing.

Here's how I do it on nights, you may be able to pull a few tips out of it despite the difference in shifts...

1) get report. You need to find a system that works for you. We can print up worksheets on each patient that lists the docs and each system for quick notes on the top third; I draw a line across the bottom about a quarter of the way up or so for my assessment and notes throughout the shift to get written in. The rest of the area is for what I get in report that doesn't fit into the top part. The part across the bottom is where I'll jot down (on the far right) what I have to get done...tests, labs, NPO after MN, change IV, change drsg, etc.

2) Before I even look at any paperwork besides checking the charts for new orders and verifying orders for drips, I assess my patients. Keep in mind that the more you do at the beginning to get organized, the better your shift will flow in general. If my patients or families have any questions I can't answer based on report (like about specific meds, orders, test results, etc.) I just tell them "I haven't reviewed all the paperwork yet, I like to make sure my patients are all comfortable, situated, and don't need any pain meds before I dig into the charts. Let me jot your question down and I'll have an answer for you the next time you see me, in about X minutes."

While in the room doing my initial assessment, I make sure to:

Flush all lines, making sure that PICC/TLC/PAC have blood return

Make sure that all fluids are running like they're supposed to be

Refill pitchers if appropriate

Check to make sure that nothing is outdated (IV tubing, IV sites, line dressings, etc.)

Check the bathroom and make sure a hat/urinal is in there and being used; if not, or if I'm unsure, I'll remind the patients about I&O's

Tidy up the room

Make sure that proper signage is on the doors (line draws, isolation precautions, aspiration precautions, etc.)

Ask if the patient anticipates the need for a sleeper, has any questions about plan of care, re-educate on fall precautions, offer to toilet

Inform the pt/family about rounding etc..."I'll be in and out fairly frequently. We are required to do an assessment and get vitals every four hours, but we pop in to check on you more often. If you need me at any time, just push that red button on your call light and either (tech's name) or myself will be in to help you." This is when I write my name, the tech's name, and the charge nurse's name on the dry-erase board.

This all gets jotted down on my area on the report sheet...it usually looks like this:

ID al code bb iso fall (for the different bands they are wearing...if one needs to be on but is not, I write it down and circle it so I know to bring one in to put on when I pass meds...ID band, allergy band, code band, blood bank band, isolation band, and fall band)

#20 LAC 3/16

LS Cr BLL

BS + 3/16 (the date is when pt reports last BM)

ed 2+ BLL (edema)

teds/SCD on

pain 0

It takes me roughly 45 minutes to do this on five patients.

3) By now the techs are (hopefully) done with vitals. I grab all my flowsheets and MARs, and go through them one patient at a time. Vitals get written on my report sheet, and I check the MARs to see what is due and jot down the BP and HR under the time for the appropriate meds; that way, when I'm pulling meds out of the Pyxis, it's right there.

4) Place any MD phone calls that I need to based on desires for sleeper, inadequate pain relief, labs/test results, funky assessments, or messy vitals. Since I work nights, it's imperative that I be on the ball with this. I jot down in my part of the report sheet who was called, when, and why..."Jones 2130 BP". When they call back I put a slash behind it with the callback time..."Jones 2130 BP/2145".

5) Glance through my kardexes...any testing that will be done gets jotted down on my papers. Check up on anything that pt/families had questions about the first time I saw them.

5) Next up is med pass. I prioritize who gets what...pt A has BP of 180/70...let's give her meds first, and note down to recheck in an hour to make sure they're working. pt B is going to radiology, let's give his next. Etc. If it's someone I know takes a long time to take their pills, or is a tube feeder, I generally save them for last if I can.

Offer to toilet again.

Answer any questions they had the first time around

Review the plan of care with pt/family and write in on the dry-erase board in the room, based on what I've jotted down on my papers from the kardex. "Dr. Smith has ordered labs for you in the morning, we'll be getting them when we do our rounding roughly around four am. We'll also be getting an EKG on you at that time. I know it's inconvienient for you to be wakened for this, but the doctors like to have all of the results in before they round for the day so that they can better plan your care and hopefully get you out of here sooner/figure out what's going on with you sooner (whichever seems most appropriate). You'll also be going to get a stress test in the morning; unfortunately I can't give you an estimated time on when that will be done. Do you have any questions about your testing that I can answer for you?"

6) Now it's time to chart! Yay! My narrative is usually short and sweet..."Assess per flowsheet. No acute physical distress noted. Pt resting comfortably in bed. Visitor @ bedside. Pt up ad lib in room with steady gait."

7) By the time I'm done charting (which is usually interupted a thousand times) it's time to start assessing all over again. BUT this time around, I know that my rooms are neat, all their questions are (hopefully) answered, and it only takes a few minutes for each patient. If the assessment is the same as it was the first time, I don't even write anything on my paper; if there is a change, that's all I jot down. Any midnight meds get done at the same time.

8) Chart my midnight assessments. Then lather rinse repeat for 0400. Whenever I can manage to squeeze it in with my charting is when I do all the other idiot paperwork.

9) 0400 rounds are when I restart all my outdated IVs, so I can get labs at the same time. If I have to do this, I warn them when I pass hs meds..."I'll be restarting your IV with my four am rounds; I know that it's not the time you'd probably like to have it done, but if I do it then I can try and get your labs at the same time and hopefully save you a stick."

9) By 0500, I'm hopefully close to having my charts closed out. I check my lab results, pull my 0600 meds, and total I&Os. Any calls that need to be made to MDs get started at 0600. I try to do my final rounds at around 0530, passing 0600 meds as I go. I also check to make sure that pitchers are freshened, hats/urinals are dumped, etc. I let my patients know that my shift will be over soon, double check that they don't have any more questions, and thank them for being such great people to take care of (when it's true).

10) Sit at my pod waiting for day shift to arrive, looking cool as a cucumber and like it's so easy on nights :)

Jeez, that was long! I left out stuff that's tele specific, like running strips. Hopefully someone finds my long-windedness helpful.

poppy07 · Mar 17, 2009

a No-No! Only chart what you have actually assessed. Plus, it seems like you are making more work for yourself. You can't actually chart a presumed assessment. tsk tsk