Help! What to look for by diagnosis?????

  1. I am a new nurse and right now I am very task oriented. I feel like I have no time for critical thinking and that all I do is pass meds and do charting. When report time comes, I often find that I have not looked for the right things and have no clue what is going on with my patient. Does anyone have a template or list of what to look for by diagnosis? For example, if someone has an "itis" you would look at the WBC and temperature. I work on a med/surg/tele floor so I see a lot of different diagnoses.
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    About nikkole318

    Joined: Sep '10; Posts: 64; Likes: 41
    RN; from US


  3. by   jadelpn
    Before you pass meds and chart, you assess. Learn to do a really good head to toe. Make note of and intervene on anything that is not within parameters for your patient.When you report, you start head to toe, either WNL for this patient or note changes. I love me a good "brain" (meaning a paper with your patients and notes LOL) and there's lots of choices of patient notes for nurses on this site. Even a sticky pad or pocket notebook. Labs--any critical highs or lows, and you should call the MD. If you have a high WBC, a low H/H, any lab value that has significantly changed for the worse, then you should let the MD know. There are those days when it seems like you have done nothing but pass meds, you are pulled in 900 different directions, but the first hour of your shift when you can assess and make note will set you up at baseline for the patients for the rest of your shift. So don't be afraid to make notes--the MD is responsible for looking at labs and figuring out what they want for different diagnosises. It is just up to us to have all of the information available to them.
  4. by   nikkole318

    It is SO hard to get all the assessments done before meds! There is just not enough time in the day!