How do you organize your clinical day?

Nursing Students General Students

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Specializes in float pool.

I feel like some days my clinical time is dictated by what time meds are given and the call lights are on. I hit the end of my shift having gotten the meds out, but not even touching on the care plan or patient education. That isn't even to mention that I still did not get time to read the chart, labs or doctor's orders. Is it just that as a student you have a hurry up and wait situation where you have to get an RN to check and watch you administer pills? I don't like the feeling that it is almost time to go and I haven't had time to chart what I have taught or what their plan for the day is (which stinks to do when it is the end of the day). I see some people with little charts that they use and I have copied a few down, but I haven't been able to find one that helps me organize my day. I realize that every day is different and some days just have more than others, but is there some general plan that would be good to know that would streamline how the day goes?

Specializes in Family Medicine.

Here is my schedule for clinical:

1.Get report from RN

2.Find and meet PCT, and ask about vitals, accu-checks, baths, and linen changes

3.Access computer and fill out top ½ of Summary Sheet, this includes:

-The names of the nurse and PCT and their phone numbers

-The patient’s initials, sex, and DOB

-Diagnosis

-Isolation/precautions/safety

-Allergies

-Code/DNR status

-List of the times medications need to be administered

-Last vital signs

-Diet, height, weight, BMI

-Important lab results, diagnostic X-rays, CT, or US

-IV site/fluids

-Activity level

-Accucheck

-Dressing or wound

-Tubes or catheters

-Oxygen

-I/O

4.Meet patient and check:

-Neuro status (are they alert and oriented)

-Safety assessment (they aren't on the floor are they?)

-Diagnosis-related assessment

-Pain assessment

-Drains/Tubes/O2

-IV: rate ____

site ____

5.Chart findings from #4

-Neuro – in Doc Flo

-Safety – in Doc Flo

-Diagnosis findings –

-Pain assessment –

-Drains/Tubes/O2 –

-IV –

6.Review MAR for Pain Meds if needed, document pain, and administer (Repeat as Needed)

OR

Review MAR and prepare for 0800 Meds (+ 0900 if time allows)

7.Administer 0800 Meds (+ 0900) and do Head-to-Toe assessment while in the room

8.Chart Head-to-Toe assessment and read latest RN Notes and History

9.Take a break

10. Write progress note

11. Continue with Meds/Patient Care/Charting

12. Say goodbye to patient

13. Report off to the RN and PCT

*If pain meds given, re-assess and chart within ½ hour

I also have a Summary Sheet that includes the information I mentioned in "3." above plus a bottom portion that I can write my head to toe assessment information on.

At the beginning of the semester, I printed out this schedule and would check off things as I went through them. After one week of doing this, I no longer need the sheet and had established a routine. The schedule was made for one patient but I still follow it with more than one patient, its just a little modified.

Last year in med-surg, I tried to follow a general schedule, but it all varied depending on pt's condition, acitivity and assistance level, etc. I used to write down all my goals for the day on a little piece of paper.

A good day would look like this:

1. Get report from RN

2. Check/review pt's chart + orders quickly to see if pt was going down for any tests, consults etc

3. Meet pt, introduce myself, check neuro status, take vitals, heart/lung/bowel sounds and any other assessment

4. Usually by then, breakfast trays have arrived. If pt needs help, do that. if not, go back and review chart & labs. Then go get my instructor to get meds, review etc

5. Go back to pt to pass meds, assist with bed bath/shower etc. Change linens

6. During any "downtime", I would fill in assessment sheets and start on my careplans (which were due on the second day of clinical)

That was pretty much all we ever had time for. We met our instructor at 7am, had a little pre-conference with the group, usually got up to the floor anywhere between 7:15-7:30. We were off the floor at noon, and had post-conference until 1. That entire schedule, plus answering my pt's call lights, taking care of any toileting/wound/functional issues, plus answering other pt's call lights... there's really not much time left for anything else.

I did find that writing down goals for the day helped a lot. Just to make sure I was making the most of my time in the patient's room, I'd take a quick look over it before I went in so I could make fewer trips if possible, and spend time charting and working on assessment sheets and care plans in between. :)

Hello!

1) Find out who my pt is, either report from nurse or from my instructor.

2) Take chart to ID my patient as I introduce myself and measure vital signs. (I was told that once you find out who your pt's are, "take a peek" at them to make sure they are well because you never know when the last time they were observed" and I take vital signs so I can go straight to #3)

3)look at meds and times given and get med flashcards ready so I am prepared to give meds.

4) I gather my equipment to give meds such as flushes, cups, syringes, needleless syringes, filter needles, alcohol pads, gauze, etc

5) I complete the pt assessment after I give meds that way I am multitasking- performing an assessment and evaluating the medications.

I perform the assessment depending on how many meds I have to give and the times I have to them. I then go on to perform any procedures client needs such as wound care and so forth. I have a patient report sheet that helps me to keep organized.

Good Luck!

Specializes in float pool.

Vindy,

What do you mean by Med flashcards? Like a Kardex?

Hi decgrad,

Med flashcards such as Pharm phlash! cards. Other companies make them as well. It's an alternative to creating your own medication flash cards that is if your professor allows you to use it during clinicals.

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