How do you manage your shift from beginning to end?

[missdeevah, NP]

i graduated in december, and started on a telemetry floor, where we get a max of 6 patients to a nurse. it can be very strenous, especially when you end up (like i did last week) with 2 patients having pauses in their rythms, and another going into supraventricular tachycardia, having to call the doctors on all of them and implement the orders, chart on interventions, outcomes and the fact that doctors were called.

i see some nurses that never stay past shift change time. i always wonder how they are always able to finish on time, including charting. i do plan on talking to a few of them to get tips on how they manage this. i don't always finish on time, though i do sometimes.

i'm curious to know...what have you found that works for you, to make your shift flow easier, and help you be done on time, or manage your time better? i mean, from start to finish...how do you plan your day? what do you do first, and what do you keep for last? how do you organize your workday?

[KnittingRN7]

Wow I work on a tele floor and our max is 4patients days/eves, and 5 at night which is still too many in my opinion. I have been nursing for 26yrs 23 on this unit. I honestly couldn't take care of 6pts. So kudos that you do. I am constantly prioritizing. I like to check my tele then go see everyone. I get bogged down because I like to do a full assessment, check labs, peek at last dr note and at least chart VS and IV status and then get their meds. This takes me 20min minimum per pt so with 6 no way. I am less worried about getting meds out on time as making sure they are safe to get the meds. Labs ok, BP, Pulse ok. I belong to the chronically late for break club so don't always get one but try to get 2. I use my charge a lot if I get really behind. They don't want overtime but I will not lose my license so take the time to chart the best I can. I do take the time to make sure care plans and education documenting is done. I think the people who get out every day on time and to break every time and still look like they have time during the day are letting some things slide. That is my opinion don't shoot me. But I would like to see their charting and I notice they are not always in their pt's rooms or have the aides do a lot of their cares. I have a different standard for my self. That is why we are fighting for staffing ratio lanuage in our contract and will probably be on the picket line in July. With all the things we are responsible for we can't go on being spread so thin. Good luck and fight for your patients and your license.

[mblount]

I have precept-ed many new grads and this is a common problem. The ones who master their work load are the ones who are happier. With that said here is my advice.

Arrive just a few minutes before report time so that you can get your stuff together and be ready for report. I like to use a form for my report that way I have the information on the patient in the same place and don't have to search for it. After report check telie strips, vs, lab, mar then go see the patient for a quick howdy do and quick assessment. When I pass out the scheduled meds is when I do a in depth assessment. I try not to streess about med times but I do try to be timely. The big thing I have found is that you need to keep up on charting and check you patients frequently. Always ask them before you leave the room if they need anything, keep their stuff close to them and the call light use drops. This helps also. There will always be days when no matter how together you are you will have one or two patients that bog you down. Just because you are doing primary nursing does not mean that you should not ask for help. We are all in the patient care business and if your sister/brother nurse needs help because they are swamped help out.

[vashtee, RN]

I have been a nurse for 1.5 years, and am still stuck on nursing-school style work. I fully assess each of my patients (before giving any meds), and I document a lot. The thing that is different in my hospital is that (most of?) the other nurses only do focused assessments (the patients often tell me I am the only person who has done a thorough assessment since they were admitted), and they document a LOT less than I do (which I know because I looked, thinking I was doing something wrong, since they all have time for coffee breaks, and I don't).

I show up 15 minutes before work starts, and print labs. I also have "brain" I set up before shift change... it has a column for each of my patients, and hourly increments along the left column. I fill in what time all meds and procedures are due for each patient throughout the day so I don't forget anything. It helps keep me organized.

When I first start my shift, I run around to make sure all my patients are alive and their IVs aren't infiltrating, make a quick note about this in the chart, write my name up on the boards, and then start my complete assessment. I usually finish right around 9, and it's time for meds. I am usually okay time-wise once the 10:00 hour passes. Until then, I am swamped.

Seriously though... I think 6 patients is a lot, if they are medically fragile or confused. Our tele patient ratio is 4:1.

[brownbook]

Try to get a routine and stick to it. Write down on paper a plan (ok I'm old I guess there is some computer app you could use.) You need to figure out for yourself what sounds good or copy what other nurses do then you can adjust it to what works for you. For example complete your rounds, try to not interrupt your rounds for "minor" problems. You may find patients in minor to moderate pain, wet/dirty linen, etc. but try to stick to your rounds. After rounds check your medications and plan to deal with the "minor" problems. Delegate if you have CNA's or other assistants on the floor. Stick to your routine unless there is an urgent crisis.

[bbie17]

I think 6 patients is alot, especially if you're working day shift. I work on telemetry as well, but we usually have 4-5 patients. Sometimes we have 6, but they're usually stable patients.

I'm a new grad, but I was lucky to have an extremely organized preceptor during my orientation who taught me how to manage time well. The way I start out my day is by showing up at 6, even though shift change doesn't start until 6:30/6:45. I'd look up labs for all my patients, check tele rhythms, write down the times meds/procedures are due for each pt, then I go thru the charts and write down any new orders so that during report, I can verify w/ the off-going nurse. All this takes about 20-30mins, so by 6:30 I'm ready to get report. I try to be done with report by 7. Then from 7-8, I go in and do complete assessment on all the patients as well as charting after each one. By 8-8:15, I start passing my 9 o'clock meds. This routine works pretty well for me, but some days, if I get an admission or a discharge right at the beginning of shift, I tend to fall behind a bit.

[HollyHobby]

From what I have seen, nurses who chronically have problems getting their work done are those who 1. take a long time to do an assessment, and/or 2. chart way too much.

Don't get me wrong, doing good assessments and good charting are (I think) the two most basic, important things. You have to be good at these things if you're going to be good at anything else. However, a time-consuming assessment is NOT necessarily a better one, and charting MORE is not always better.

As far as assessments go, I think that with practice it should only take 5 minutes for a relatively uncomplicated patient, and maybe 10 for a difficult one. This comes with practice, and eventually you should be able to assess several things at once. It's equally important to be able to rapidly detect an assessment CHANGE in your patient, another thing that comes with time. It took me a good few years before I could easily "see the whole picture".

Never over-chart. As an extreme example, I used to work with a smart young woman who would always end up charting for hours after her shift. I couldn't figure out why until I read her charting. This is an actual quote: "Administered Primaxin 400mg/ 200cc D5W IVPB per infusion pump over one hour via 20g angiocath R FA. Please see MAR for further documentation." She'd document like this, in the nurses' notes, about every medication she gave.

Now, why in the world would anyone write that? It's already documented on the MAR. Double charting is pointless and distracting. Also, when a person writes pages and pages about insignificant horsehockey, nobody can find the stuff someone might actually need to know. When did Mr. Jones have chest pain? When did the RN notify the doctor? Gotta read ten pages to find out.

If your hospital has charting by exception, do it that way. If something is abnormal, if something changes, chart it. Also chart education and any other care you gave. But it shouldn't take ten pages to give a clear idea of what happened during your shift. (That being said, there HAVE been times when I've charted 10 pages on one pt, when that pt spent the entire shift trying to die, but that doesn't happen every day.)

As far as my routine goes, I arrive at work a few minutes before I'm "legally" allowed to clock in. I put up my stuff, wash my hands, and clock in. I make a brief timeline for each pt: 19, 20, 21... through 07. I circle the times when meds are due and make note of anything else that must be done for that pt during my shift. I write an circled A above 20, 00, and 04 for "assessment". I write I&O above 22 and 06. Anything I need to do (give blood, draw labs, EKG, etc.) I circle, and when it's done I put an X through it. The goal is to have all the circles X'ed out by 0700.

I also have a little section to note things I need to pass along to the next shift, so giving report will be complete and concise.

I jot notes to myself in the margin. I can pretty much remember my whole assessment without making a note, but if I need to make sure to remember something ("heart murmur") I write it down. PRN meds, calls to docs, pretty much anything I do gets jotted down, with the time, so I can chart everything later.

Except for rare occasions (everyone has rough days/nights) I have time to chat with my patients, give them extra care, do the thousands of piddly-**** stuff we have to do like label the tubing and line up the toiletries in neat rows on the bathroom sink, and of course help my co-workers who may not be having such a good day.

I only ask the aide for assistance if I have a very heavy assignment or during an emergency situation. I always try to do my own I&O, wights, toilet my own patients, take out my own trash/linens, do my own accuchecks, etc. I greatly appreciate my aide and know she is busy, so I try to take as much load off of her as possible. Most of these things I do so the aide doesn't have to are things I can easily do while I'm in the room anyway.

[lkwashington]

I work night shift 7p-7a. I am a float nurse so it depends how my night start off. Usually after receiving report because we do bedside report and check charts every shift with the off going nurse. I review labs, history, dr notes, and any test results done. I start my patient care at 2000, this would include assessments and meds. Administering meds we have an hour before and a hour after the schedule time. I work on five different units. It depends on what unit I am on and number of patients including acuity levels.