How to be organized in med surge clinicals

verene, MSN · Aug 22, 2019

What works for me is to get a flow for the day - I currently work on a psych unit so some of it is different from med surg but idea is similar. I get report from the off-going RN. Most of my patients are still asleep when I come on in the AM so I typically take the 30 minutes after report to review labs, look up med times, and get my brain-sheet organized for the day (e.g. who has meds due when, who I need to follow up with MD or pharmacy for, who needs vitals or would care, any admits or discharges for the day and is there any prep for these that is needed - admit packets or meds packed- etc). Then I go around and introduce myself to patients who are awake and start vitals & med pass. After meds, I check in with MD and have IDT meeting, and make calls to pharmacy, this is also usually when I have admits and discharges. Usually to take my lunch before patients go to lunch. Then afternoon med pass, medical/wound care, more follow up with patients & pharmacy/providers, and a stretch of time to catch up on documentation, also may have afternoon admit or discharge. Afternoon report with floor staff (who work 8s when I work 12s). Another stretch to be out in the milieu , work on any remaining documentation, and prep for night shift (stocking, copies etc). Dinner time med pass and then shift change. Assuming I don't have a medical or psychiatric emergency to deal with - in which case I just make things work and get back on track later.

When I worked swing as a CNA I'd get report, then go around to each room to introduce myself and take vitals, update the boards with teams for the shift etc. Then I'd typically partner up with the other CNA on the hall and we turn all our patients and do bedbaths for those on evening schedule. Then take 15s. Then dinner for patients for those who needed feeds and general assistance on the unit to patients and families. Then lunches for us. Then another round of turns. Then various things like taking out trash, cleaning common spaces and patient rooms, etc, then another round of turns, helping patients get ready for bed, and leaving the unit prepped for night shift (rooms and common areas picked up, restocking rooms, etc) and finishing up any documentation that hadn't been done earlier.

I'd ask the RNs on the unit you are on how they like to structure their day - every one is a little different, but seeing what others do can help you form a plan for yourself that makes sense for the unit you are on. It can also help when you get more patients to be more organized. After being a CNA with multiple total care patients I found having only one patient really hard as nursing student because I had SO MUCH DOWN TIME, which was good for filling out care plans and looking stuff up - but I generally would make myself useful to the CNAs and RNs on the unit which let me do/see more than just my one patient - and I talked to my instructor and she ended up giving me more complicated patients which kept me busier - which actually made it easier to organize because I couldn't waste time. By the time I was taking full loads in practicum I was super organized, because I had to be.

bitter_betsy, BSN · Aug 23, 2019

We know who our patient is the day before and we have to submit our labs and meds and one piece of our documentation related to their diagnosis the morning of clinical (so we have to go to the floor the day before and get all of our info to do said prework). On the few days we haven't had to do this, I keep a small notebook in my pocket, write down their meds, labs and do a quick search of their diagnosis to really understand what is going on with them. I stay after everyone else leaves and look up the remaining information that I need to complete my paperwork.

Honestly, once our clinical instructor lets us go, I just stay attached to my nurse and that usually results in me getting to do everything else that I'm allowed (it also means I sometimes won't do a 2nd assessment on a really sick patient). I just stay with the nurse and go with them through all their patients and assume they are all mine. It results in me getting to do and see more things that if I just hover over my patient. I've had some of my best experiences with people that weren't my patient.

At the end of the day, I will sit down at the computer and get any information for my paperwork that I need, follow up with the nurse to answer any outstanding questions, then I go home and complete the documentation while its all fresh in my brain.

Am I following the rules? Probably not, but my instructors don't complain because I am never sitting down and the nurses are always happy with my participation. I've even had nurses request me for the day because they had something they wanted me to specifically be part of as a learning experience.

I know we have to do documentation, but if clinical becomes about paperwork more than it is about learning, we will never make good nurses. I know nurses have to document, but if they only know how to document and not how to coordinate patient care, they won't make it past that first year. - just my opinion!

nurseburst, ASN, BSN · Aug 23, 2019

Good question. It is tough to get a routine down and just know that. We also use powerchart at my hospital (aka Cerner). First thing is first, add your patients to your list so they show up on the care compass. The care compass shows you upcoming tasks that need to be completed. This is useful but this isn't all you should look at. You can also see most recent orders/lab results here in Care Compass as "Nurse Review" it there. This is awesome because sometimes patients have been here for a week or more and it can be hard to filter through old/new orders.

Get your SBARs. Along with the SBAR, a lot of us night shifters use a separate sheet that we can quickly add Room #, Med Times (including if they need insulin, BP & HR to be closely reviewed for BP meds, etc), Procedures to plan for, K/Mag Sliding scale (Something we do at my hospital) and also charting check-offs. I've included a copy of my "cheat sheet" and I recommend if you want to use it to make your own or customize it! ?

Many other nurses simply fold their SBAR and on the back they write these things. So, it's complete preference.

Labs are important and procedures too but what is your patient here for? What should we focus on? These are what you should write down on your SBAR. For example, if your patient is here for CHF: What was there BNP on admission? Strict I&O, Wts... Are they on IV Lasix or PO? What did their CXR reveal on admission vs now? If the patient is here for CKD or AKI: What is there BUN or Creat? Is it coming down? Are they getting fluids or are they a dialysis patient? You may not see these patients because they are usually on tele! But as you move along, you will learn what to look for. In the meantime, ask your preceptor/instructor what THEY would look for?

By having a good picture you can kind of establish a POC (Plan of Care) for your day. It's a lot as we are essentially a coordinator for all of a single patient's care. What's the plan for discharge? That's also another thing to write down and have an idea of.

Usually, at night, I come in and review charts as much as I can so I have a good idea of what's going on with my patient and I develop a plan on my cheat sheet of what I need to do during the night. But, at any time... that can change. You may have to call rapid on a patient. Your patient may need an additional dressing change. There is so much you simply cannot plan for. So, do the best you can with knowing when meds are due (unless orders change), procedures, labs that we are monitoring closely, is there a change in labs, look for new issues with your patient.

After I develop a plan, I see the patient that needs me first, (High BP, pain, etc.) This is where prioritization comes into play! And you will learn this as you go. If I can assess during my medication pass, I do. If not, I come back. We have hourly rounding at our hospital, every 2 after 10 so I keep up with when I was last in a room to make sure I am checking on them frequently. For my sicker patients, I am rounding more frequently.

Just breathe. You are going to do fine. It takes time and some working out kinks to get a routine down. You cannot always fix or address everything and that's ok. Just keep your patients safe, provide the best care you can, and ALWAYS ask if you are not sure about something.

Sorry long-winded. ? Have a good one!

Cheat Sheet 1.docx

Zohazaidi · Aug 31, 2019

On 8/22/2019 at 8:42 PM, nurseburst said:
Good question. It is tough to get a routine down and just know that. We also use powerchart at my hospital (aka Cerner). First thing is first, add your patients to your list so they show up on the care compass. The care compass shows you upcoming tasks that need to be completed. This is useful but this isn't all you should look at. You can also see most recent orders/lab results here in Care Compass as "Nurse Review" it there. This is awesome because sometimes patients have been here for a week or more and it can be hard to filter through old/new orders.
Get your SBARs. Along with the SBAR, a lot of us night shifters use a separate sheet that we can quickly add Room #, Med Times (including if they need insulin, BP & HR to be closely reviewed for BP meds, etc), Procedures to plan for, K/Mag Sliding scale (Something we do at my hospital) and also charting check-offs. I've included a copy of my "cheat sheet" and I recommend if you want to use it to make your own or customize it! ?
Many other nurses simply fold their SBAR and on the back they write these things. So, it's complete preference.
Labs are important and procedures too but what is your patient here for? What should we focus on? These are what you should write down on your SBAR. For example, if your patient is here for CHF: What was there BNP on admission? Strict I&O, Wts... Are they on IV Lasix or PO? What did their CXR reveal on admission vs now? If the patient is here for CKD or AKI: What is there BUN or Creat? Is it coming down? Are they getting fluids or are they a dialysis patient? You may not see these patients because they are usually on tele! But as you move along, you will learn what to look for. In the meantime, ask your preceptor/instructor what THEY would look for?
By having a good picture you can kind of establish a POC (Plan of Care) for your day. It's a lot as we are essentially a coordinator for all of a single patient's care. What's the plan for discharge? That's also another thing to write down and have an idea of.
Usually, at night, I come in and review charts as much as I can so I have a good idea of what's going on with my patient and I develop a plan on my cheat sheet of what I need to do during the night. But, at any time... that can change. You may have to call rapid on a patient. Your patient may need an additional dressing change. There is so much you simply cannot plan for. So, do the best you can with knowing when meds are due (unless orders change), procedures, labs that we are monitoring closely, is there a change in labs, look for new issues with your patient.
After I develop a plan, I see the patient that needs me first, (High BP, pain, etc.) This is where prioritization comes into play! And you will learn this as you go. If I can assess during my medication pass, I do. If not, I come back. We have hourly rounding at our hospital, every 2 after 10 so I keep up with when I was last in a room to make sure I am checking on them frequently. For my sicker patients, I am rounding more frequently.
Just breathe. You are going to do fine. It takes time and some working out kinks to get a routine down. You cannot always fix or address everything and that's ok. Just keep your patients safe, provide the best care you can, and ALWAYS ask if you are not sure about something.
Sorry long-winded. ? Have a good one!
Cheat Sheet 1.docx

Thank you so much and for the template?

On 8/22/2019 at 8:22 PM, bitter_betsy said:
We know who our patient is the day before and we have to submit our labs and meds and one piece of our documentation related to their diagnosis the morning of clinical (so we have to go to the floor the day before and get all of our info to do said prework). On the few days we haven't had to do this, I keep a small notebook in my pocket, write down their meds, labs and do a quick search of their diagnosis to really understand what is going on with them. I stay after everyone else leaves and look up the remaining information that I need to complete my paperwork.
Honestly, once our clinical instructor lets us go, I just stay attached to my nurse and that usually results in me getting to do everything else that I'm allowed (it also means I sometimes won't do a 2nd assessment on a really sick patient). I just stay with the nurse and go with them through all their patients and assume they are all mine. It results in me getting to do and see more things that if I just hover over my patient. I've had some of my best experiences with people that weren't my patient.
At the end of the day, I will sit down at the computer and get any information for my paperwork that I need, follow up with the nurse to answer any outstanding questions, then I go home and complete the documentation while its all fresh in my brain.
Am I following the rules? Probably not, but my instructors don't complain because I am never sitting down and the nurses are always happy with my participation. I've even had nurses request me for the day because they had something they wanted me to specifically be part of as a learning experience.
I know we have to do documentation, but if clinical becomes about paperwork more than it is about learning, we will never make good nurses. I know nurses have to document, but if they only know how to document and not how to coordinate patient care, they won't make it past that first year. - just my opinion!

Thank you ?

Zohazaidi · Aug 31, 2019

On 8/22/2019 at 2:36 PM, verene said:
What works for me is to get a flow for the day - I currently work on a psych unit so some of it is different from med surg but idea is similar. I get report from the off-going RN. Most of my patients are still asleep when I come on in the AM so I typically take the 30 minutes after report to review labs, look up med times, and get my brain-sheet organized for the day (e.g. who has meds due when, who I need to follow up with MD or pharmacy for, who needs vitals or would care, any admits or discharges for the day and is there any prep for these that is needed - admit packets or meds packed- etc). Then I go around and introduce myself to patients who are awake and start vitals & med pass. After meds, I check in with MD and have IDT meeting, and make calls to pharmacy, this is also usually when I have admits and discharges. Usually to take my lunch before patients go to lunch. Then afternoon med pass, medical/wound care, more follow up with patients & pharmacy/providers, and a stretch of time to catch up on documentation, also may have afternoon admit or discharge. Afternoon report with floor staff (who work 8s when I work 12s). Another stretch to be out in the milieu , work on any remaining documentation, and prep for night shift (stocking, copies etc). Dinner time med pass and then shift change. Assuming I don't have a medical or psychiatric emergency to deal with - in which case I just make things work and get back on track later.
When I worked swing as a CNA I'd get report, then go around to each room to introduce myself and take vitals, update the boards with teams for the shift etc. Then I'd typically partner up with the other CNA on the hall and we turn all our patients and do bedbaths for those on evening schedule. Then take 15s. Then dinner for patients for those who needed feeds and general assistance on the unit to patients and families. Then lunches for us. Then another round of turns. Then various things like taking out trash, cleaning common spaces and patient rooms, etc, then another round of turns, helping patients get ready for bed, and leaving the unit prepped for night shift (rooms and common areas picked up, restocking rooms, etc) and finishing up any documentation that hadn't been done earlier.
I'd ask the RNs on the unit you are on how they like to structure their day - every one is a little different, but seeing what others do can help you form a plan for yourself that makes sense for the unit you are on. It can also help when you get more patients to be more organized. After being a CNA with multiple total care patients I found having only one patient really hard as nursing student because I had SO MUCH DOWN TIME, which was good for filling out care plans and looking stuff up - but I generally would make myself useful to the CNAs and RNs on the unit which let me do/see more than just my one patient - and I talked to my instructor and she ended up giving me more complicated patients which kept me busier - which actually made it easier to organize because I couldn't waste time. By the time I was taking full loads in practicum I was super organized, because I had to be.

Thanks a lot! This clinical I’m learning so much and my instructor is amazing! I think I’ll be fine?