I'm looking to get some insight from other med-surg units regarding how you handle charge nurse shift handoff.  Not bedside handoff, just charge nurse handoff.

I currently work on a 48-bed medical-surgical unit where our charge nurses (two during the day and one at night) are free charges (no patient assignment). In our current format at shift change, we give a brief report on essentially every patient on the unit.  As we go, we give additional focus to discharges, admissions, and any issues. As you can imagine, this can make report quite long (>1 hour is not uncommon) and, at times, feel redundant-especially since much of the information is already available in the EMR.

I'm exploring ways to improve efficiency while still maintaining safety and situational awareness.  One of the biggest things that I have become convinced of in the last few years both as a bedside and charge nurse is that longer report is absolutely not necessarily better report.  I honestly have come to feel that as much as 2/3 of the time I have spent in charge report is redundant time going over excessive details that are never relevant during the shift.  Even when I do need to know details about a patient, the report from charge report is usually not enough information anyway, and I end up having to talk to the primary nurse and/or dive through the chart for more information anyway.  I have been asking myself more and more, if I have to do all that whenever I need relevant information, why I am I spending an hour at the beginning and end of every shift trying to do a brief report on everyone?

I've been reading about more exception-based or operational handoff models, where the focus is more on:

• Unit census and staffing
• High-risk or "watch list" patients
• Admissions and anticipated discharges
• Safety concerns or recent events
• Operational/unit issues
• They would focus on these rather than going patient-by-patient. 

However, most actual research or organizational recommendations focus on administrative-style handoffs for directors and managers.  I can find almost nothing specific to charge nurse handoff, and the little that I can find is almost always focused on an ICU setting.  So I would like to put it out there here to see if I could get some feedback very specific to a Med-Surg Setting, how do you all handle these sorts of things in practice?

• Do you give report on every patient, or use a more focused approach?
• If you've moved away from full patient-by-patient report, what does your structure look like?
• Have you implemented any kind of charge nurse log, dashboard, or written handoff tool?
• How long does your charge report typically take?
• If any of you moved away from a full patient-by-patient report, did you encounter resistance?

I'd really appreciate hearing what has (or hasn't) worked for your med/surg units. I'm especially interested in what's been sustainable long-term.  If anyone knows of any research related to this topic, or have alternative handoff templates, I would appreciate information on them.  

Thanks in advance for sharing your experiences!

I am considering a move to the emergency room setting.  I have only filled in at the ER occasionally.  I am currently working a Med-Surg floor at night, and have been for about 9 years.  Previous to that, I worked in a hospital clinic, in a skilled long term care facility and for a private physician's office.  

Has anybody made the move to ER from Med-Surg, and if so, did you find the transition doable as far as the learning curve?  I am hesitant to make the switch as I am afraid my peers may think that I am not fast enough or efficient enough for the ER.

Please share your thoughts.

Thank you!

I feel like I am being asked to build a house but was given only scotch tape as a tool. My preceptors, charge nurses, and manager have all made clear "this is a 'heavy' floor..." and "this unit has the highest turnover rate in the hospital". I get the impression that the only nurses who stay are those who have a nurse residency obligation to fill. I'm not sure if they seriously expect someone to magically "know" the whole department, or if they are just biding their time until I quit. 

As a first-time union member, I'm concerned I need to get the union involved to protect myself against missing those shifts scheduled without my knowledge.

I accepted this position for extra money while I apply to grad school and for experience within California that will hopefully make other positions more likely to take my resume seriously. I am concerned that instead, this will become a black mark on my record I have to leave off my resume if the negligence of orientation continues. Other than applying for other jobs and contacting my union rep, how do I ensure that my needs are met?
 

So I was just wondering what your unit's CNA to Patient ratio is and if you have had experiences similar to mine. And what have you done to minimize the situation? Maybe I could make some suggestions with my manager or something.

I have almost met my 2 years on med/surg. I have been a nurse for 8 years now! I plan to sit for my CMSRN. I was hoping some of you could give me some insight, what to expect for the exam?

Thanks,

Kelly

I just started working on a med surge floor at a hospital where i live. I just came off orientation and now am on my own.. I find it extremely difficult handling 5 or 6 patients, even if I get help from the other more experienced nurses. Before I was hired to work on the floor, I had been toying with the idea of going into the ER. I know that working in the ER has to be stressful too. However, I keep thinking that it might have been less stressful if i had been hired in the ER as opposed to med surge. Can some of you experienced nurses share some feedback on this scenario? Is the ER relatively less hectic / more manageable than a medsurge floor? I'm thinking about asking for a transfer to the ER if I feel that I'm not going to make it on my own on the floor.

thanks

Pt was given 3.25 mg of Coreg at 2100. Cardio comes unglued that the Coreg was given, then cancels study due to an unrelated (really, it was a "We don't have the ability to do this procedure due to his size" and "We didn't know he was actually this sick, its not safe") reason. Another nurse is acting like I should loose my license, but there was no order to hold ANYTHING. Nothing. Just NPO. 

How wrong was I? Yes, I'm beating myself up with the should've, could've, would've thoughts. In the end, the cancelation had nothing to do with the med, but still... I should've caught it.

what you usually do once you punch in, and describe your daily tasks, and

time management, and organization skills until you leave at 7pm? I have about 10mos of experience under my belt, i am currently

working at a sub-acute unit/rehab floor at one of the long term care facilities

in nj. also, do you think my experience working there will somehow be helpful?

thank you very much!! any tips, suggestions and advice will be greatly appreciated.

Yet I am so so stressed out about work. I have improved with charting speed, protocols, and when I’m made aware of mistakes I really do try to learn from them. I definitely have improved but I don’t think I’m at the level where I’m supposed to be. And I also think I’m being hard on myself but it’s hard to not compare myself to the other new grads who leave shortly after shift change. 
 

I wouldn’t consider myself an anxious person but I have never cried so much. I dread going into work. I’m not used to night shift and already have trouble sleeping during the day but on top of that I have dreams about work and messing up at work. My tolerance for getting overwhelmed is getting smaller. 
 

I have a 4 year contract with this hospital and 1 year of commitment before transferring units. I really want to stick with this for at least 6 months but I feel like this job is leeching into my personal life way too much. 
 

I would appreciate advice. Or even words of encouragement. I feel like the biggest baby ever but I don’t know how else to get help without owning up to how I really feel. 

I have been a practicing RN since February. I had been working at a smaller community based hospital on the med-surg floor. I recently transfered within the company to a large medical center on a surgical floor.

I am really struggling here and am at my wits end. I do well at my job. I receive compliments and praise. However, I hate it. I am so exhausted at the end of each shift. I had been working full time days and recently converted to full time nights. I am seeing the benefits of nights on this floor as the insanity is toned down approximately 10%. However, I have no time for myself. My sleep schedule is so topsy-turvy that I cannot eat. I find myself sitting at home and starring into oblivion but I cannot sleep. I then proceed to cry like an infant child.

But do not misunderstand. It is not simply night shift transition. It is nursing itself. Or perhaps med-surg nursing. I work so hard, but it never seems to be enough. I count myself lucky that I do not have to stay 2 or 3 hours past my shift to chart. I have made it an extreme priority to never do that, but in turn by the time my shift is over I am praying for a bolt of lightening to strike me down so I do not have to return the next night.

I am so disappointed. In myself. In this career choice. I want to quit. I want to walk right into work (I am still finishing up my orientation on the new surgical floor) and hand over my badge. However, this company is the largest employer in my tristate area. I do NOT want to become a DNR with them. There are many opportunities there. However, I don't think I can make it six months.

I have also developed huge trust issues with upper management. When I got hired at both of my jobs, I was given the rose colored glasses tour. The "We have strict pt to staff ratios", "We only care about delivering the best care while maintaining employee satisfaction". Immediately my ratio AND the aides ratios were debunked. When I asked about them, people just roll their eyes and say, "you fell for it too". It makes me really depressed. I am really trying to be the hard ass nurse. The "we will prosper!", but deep down I feel like I am defeating myself. I have been trying to mold these floors into something I love. I have been trying to say, "my job matters. I am a great nurse. I make a difference. It isn't just about money". But the ONLY thing keeping me at this job is my paycheck and the disappointment in my husbands eyes (which will soon breed a resentment, I know).

All of this stress in my career has put a real toll on me healthwise. I cannot sleep but am forever tired. I am frequently nauseated and tearful. My husband and I would like to try and have a baby, but my stress levels have left us without results for the past 6 months. My husband fortunately has a career in a field that he absolutely loves and fulfills him intellectually and in turn, us financially. I get the feeling he is tired of hearing all this. I know he knows I want to quit. I just see such disappointment in his eyes, which in turn makes me more depressed.

I have been thinking about ED nursing/ Labor and Delivery/ any other field. My two great friends are ED nurses and always provide me encouragement that they felt the exact same way in med-surg. I have six months before I can transfer or take the risk of turning in my badge and say I just can't work this floor anymore. I know it's only 6months, but life is very short and the past 8mos have already taken a large toll.

This post is incredibly long. I don't really know what I am looking for. I haven't really shared how incredibly unhappy I am with my supervisors because I am scared they will tell me what I secretly already know: Get over it or Get out.

I have used this site for 4 mos reading similar posts. I felt it was my turn to let it all out, even if no one reads it.

How Does Dialysis Work?

Hemodialysis

Hemodialysis is administered either through a central venous catheter, an AV fistula, or an AV graft. These are special access sites that are placed by surgeons. The central catheter tends to look like a larger than usual central line. Never use this site to flush or for medication! It will usually be marked very clearly to avoid this. The AV (arteriovenous) fistula or graft will be located in the large artery/vein of an arm. A specially trained dialysis nurse is the only one to access these sites, using a needle to connect the site to the dialyzator, a large machine that filters the blood, balances electrolytes, and removes excess fluid. Hemodialysis can take 3 to 5 depending on the patient's tolerance and other medical conditions.

Hemodialysis patients have a regular schedule of when they go to have their dialysis done. Make a note of when this is. It is usually something like "Tuesday, Thursday, Saturday" or "Monday, Wednesday, Friday." Find out when your patient's last session was or if they have missed any recent appointments. Letting the doctor know you are taking care of a dialysis patient will help to get the nephrologist on board to give specific orders regarding how often dialysis is given in the hospital.

Peritoneal dialysis

Peritoneal dialysis is administered through a catheter placed in the abdomen. This is a type of dialysis that is more commonly used in home situations and can be self-administered. The patient infuses the dialysate solution into their peritoneal space (which functions as a semipermeable membrane). The solution needs to sit in the peritoneal space for anywhere from 2 to 6 hours, depending on the patient.

Common Complications

With dialysis patients, the main complications to watch for include the following:

1- Infection at the catheter site

Teach your patient to be on the lookout for any redness (especially streaking), swelling, tenderness, or foul-smelling drainage from the dialysis site.

2- Fluid imbalance

With dialysis, large amounts of fluid are moved in and out of the body in a matter of hours, something that happens through healthy kidneys more gradually. The dialysis nurse will keep a record of blood pressure(s) throughout the procedure and will let you know, as the floor nurse, if you need to contact the doctor regarding any abnormal readings. This fluid shift can cause low blood pressure. If you are aware that your patient is receiving dialysis on your shift, you'll want to make sure and check with the dialysis nurse regarding which medications to hold. This usually includes any blood pressure medications. 

3- Infection at the site of dialysis access

Again, you are responsible for assessing these sites for any redness, swelling, tenderness, or foul odor. Ongoing infection prevention teaching is key for these patients.

4- Electrolyte imbalance

It's not just fluid and wastes that dialysis filters out. It also filters out electrolytes. Labs are usually taken daily on these patients to watch their electrolyte levels for this reason. Keep in mind that it is not unusual for dialysis patients to have electrolyte levels that tend on the high side because their kidneys are no longer filtering.

Dialysis is a life-saving procedure for those with kidney failure. An accurate, focused assessment and knowledge of common complications will enable you to take excellent care of your dialysis patient!

Share your knowledge, insights, and questions

References/Resources

5 Complications of Hemodialysis: Verywell Health

Dialysis Nursing Basics You Need to Know: Straight A Nursing

I know it probably depends on the med itself, but in general, can anyone answer what happens when an IV med is given too fast?

I was very lucky to have some amazing people to work with during the year I was on a medical-surgical floor. Most everyone was supportive, helpful, and worked well together, and this really made each shift more enjoyable, even during the hard times. Not every place has this, but I was super grateful and thankful for the people I worked with.

The good, the bad, and the ugly happens on the medical-surgical floor.  With anywhere from 3 to 6 patients a shift, some patients more critical than others, and some patients more time-consuming than others, one never knows what kind of shift they're going to have. It's imperative to have a good CNA when the patient-to-nurse ratio gets high, but unfortunately, that doesn't always happen.  Those shifts were the worst. One had to rely on time management and prioritization to make it through these shifts. It for sure was not a lie that medical surgical floors improve time management and prioritization in new nurses. Though this could easily be learned in other units as well, there is something about medical surgical floor time management skills that are respected across the hospital.

On medical-surgical floors, nurses often have to think for themselves. Often, medical-surgical nurses aren't listened to by doctors and don't often have support systems outside their unit. These nurses are questioned and sometimes even ignored despite their knowledge. I was lucky on my unit to typically have decent doctors, but even still, we struggled with getting what we needed for our patients. We had to learn how to navigate doctors and patients and communicate well.

Medical-surgical floors are not for the weak. The nurses that stick around on these floors become experts in their field. Many other units could not do what medical-surgical floor nurses do, and this is due to harsh conditions, unsafe nurse-to-patient ratios sometimes, lack of CNAs, meaning total care for patients, and a wide range of patients with different needs and different levels of care required. While they aren't always respected, medical-surgical floor nurses are often the backbone of nursing. I believe this is why teachers advise nurses to start out on these floors.

Every hospital has its own set of problems depending on the people and the way they are run. It's important to scope out some of these problems during the interview process and determine what they are willing to deal with and what they aren't. This applies no matter what unit a nurse plans to work at.

Not everyone needs to start out on a medical-surgical floor. Many units are so different from medical-surgical floors, and not every nurse would do well on a medical-surgical floor. I was lucky enough to have such a wonderful team by my side that I was able to learn so much through my experience. I'm glad to have started out on a medical-surgical floor, and I think it's important for nursing students to have an open mind about starting out on a medical-surgical floor.

The overwhelming majority of nurses have likely heard the commonplace saying that "If it was not charted, it was not done!" Thus, the patient's medical record must contain enough pertinent data to enable each member of the healthcare team to make clinical decisions and provide the patient's care in a smoothly integrated manner. The medical record is also interchangeably known as the patient's chart. In addition, there are multiple different ways for nurses to accurately document the nursing care they have provided in the medical record. In fact, no one way is correct or incorrect. However, some types of charting are more conducive to certain nursing specialties and settings than others.

The spotlight shall now be pointed toward the focused documentation style, which is a very underrated type of charting for nurses. The focused documentation method is highly advantageous because it is versatile and adaptable enough to be integrated into virtually all clinical settings that require accurate charting. Focused charting is also quick, short and concise, and these happen to be immensely helpful attributes in today's fast-paced healthcare environment that can leave harried nurses feeling as if time is always ticking away. Moreover, focused charting nicely organizes subjective and objective patient data followed by a clear-cut nursing action and one or more outcomes of the action. Additionally, focused charting swiftly intermingles several facets of the nursing process such as assessment, outcomes identification, planning, implementation and evaluation into one smallish paragraph.

Finally, the focused documentation style's main advantage is the reality that it focuses on the client's needs from a holistic point of view (Hope, 2012). In essence, focused documentation has a purposive focus that is set squarely onto the patient. Focused charting entails use of the data, action and outcome (DAO) format, more commonly known as the data, action and response (DAR) format. It is now time to read the following passages, which are examples of nurses' charting that employ the focused style of documenting.

• D - Incision to left knee s/p total knee arthroplasty performed 24 hours ago is 14.5 centimeters long, approximated with staples, warm and dry to touch, with trace edema and a small amount of sanguinous, nonodorous drainage noted.
• A - Left knee surgical incision was cleansed with dermal wound cleanser, patted dry with one 4x4 gauze and covered with a dry bordered non-adhesive dressing per physician's order.
• O - Dressing remains clean, dry and intact at this time. Patient rates current pain level as a '1' using the numeric pain scale and is able to use the continuous positive motion (CPM) machine without any issues noted at this time.
• D - Patient complains of headache lasting for 20 minutes duration; he describes the pain as dull and constant, and rates pain level as a '4' on a scale of 0 to 10 using the numeric pain scale.
• A - Administered acetaminophen (Tylenol) 325mg, 2 tablets orally per PRN physician's order for mild pain rating.
• O - Patient rated pain level as a 0 on a scale of 0 to 10 using the numeric pain scale upon reassessment. He is observed ambulating to the bathroom in his room using a rolling walker.

The focused method of documentation is versatile enough to be utilized in a wide assortment of clinical areas and specialties such as medical-surgical nursing, orthopedic nursing, long-term care, physical rehabilitation, addictions, psychiatric nursing, step-down, progressive care, private duty, home health, hospice, adult day care, and many other spheres. This particular type of charting tends to save time since it rapidly gets to the point: it describes the problem followed by the nursing action(s), and captures the results or outcomes that arose as a result of the interventions that had been carried out. Since nursing documentation is one of the more important tasks that nurses accomplish on a day to day basis, perhaps this style of charting might be tremendously useful in the area of nursing where you practice. As always, "If it was not charted, it was not done."

References

Hope, I. (2012). Charting for nurses. RN Speak. Retrieved from Charting for Nurses

As a nurse caring for a patient with delirium or dementia, the late afternoon can be a difficult time of your shift, and for some patients, it can lead to changes in emotions and behaviors ranging from one person to another. This is a phenomenon called sundown syndrome. There is no exact reason to explain why this happens, but research has suggested it can be caused by a disruption in the circadian rhythms. Nurses must be equipped to handle all types of scenarios that present themselves during a shift, but in the case of a sundowning patient, things can go from bad to worse quickly.  Now that we know what sundowning is, what behaviors do we look for in our patients?

Signs of Sundowning

Patients can experience sundowning at any stage of dementia, but most commonly in the middle to late stage. The most common changes in behavior are:

• Agitation or irritability
• Restlessness or pacing
• Crying or sadness
• Yelling or shouting
• Increased confusion
• Hallucinations or delusions
• Wandering
• Sleep disturbances
• Violence

Interventions to Prepare and Manage

1- Start to remove stimulating factors

Take notice of things that may aggravate the patient, such as noise, lights, too many people/disturbances, soiled clothing, etc. Minimizing physical, visual, and auditory clutter, which can be sundowning triggers. Also, if the patient normally wears glasses or hearing aids, it is a good idea to make sure they have them to avoid unnecessary frustrations.

2 - Keep the patient in a consistent routine

New changes to routines may cause anxieties in your patient that they cannot articulate, so they act out instead. Habitual routines can be comforting when a patient is in a hospital setting. It is also important to try and maintain a regular sleep/nap schedule, as being overly tired can contribute to a possible cause of sundowning.

3 - Monitor the patient’s diet

The patient may be sensitive to missing meals which may affect blood sugar and mood. Keeping adequately hydrated and nourished throughout the day will help to avoid nutritional triggers.  Reduce the amount of caffeine and sugar, especially later in the day, as they can be overstimulating.

4- Nonmedication therapies

Promoting a calming environment for the patient can work wonders to ease into the sundowning areas. Playing soothing music and sounds is helpful as well as keeping photos of loved ones in sight for comfort. If they are restless, try a simple game or activity for distraction or read a book to the patient.

5- Plan for sleep and night-time disturbances

It can be very likely that a patient experiencing sundowning may continue into the night. Keep the lighting bright during the day and dark at bedtime, and make bedtime at the same time each night. Keep the room temperature in a comfortable setting. Check for medication side effects that may cause sleep disturbances.

6- Prepare for both nurse and patient safety

The patient may begin to wander or attempt to leave the room as confusion sets in, so it is important to remove all fall or tripping risks, such as electrical cords or objects on the floor. A bed alarm is sometimes necessary in certain cases. Some patients will require medications or restraints for violent behavior to protect the patient, other patients, and staff. Keep a safe distance to avoid injury if the behavior is escalating. Only use restraints, if necessary and provider-ordered, as this will further aggravate the patient.

Conclusion

At some point or another, you may have to care for a patient experiencing sundowning. Knowing important triggers and interventions can make your job as a nurse much more effective. Verbal communication is key with coworkers in working together to care for the patient during this time. Discussing your sundowning care plan with the oncoming nurse at shift report can help make this transition easier for all involved. The next shift will thank you for it!

References/Resources

Tips for Coping with Sundowning

Sundowning and dementia

Sundown Syndrome

Thanks.

Does anyone work here? This hospital is in the Bronx NY. I was wondering if there are certain skills i must know ect. Generally speaking what skills must i KNOW while working at a med surge floor? Any tips? Im scared but excited!

I'm very happy and can't wait to start, but I'm also nervous. My biggest fear is making a medical error with medication or anything else. I originally applied for a full-time night position, but ended up getting a part-time day position on this particular unit. It's been 10 months since graduating nursing school, so I'm so grateful for this opportunity and I really want to be successful. I also think it will be better for me to start out as a part-timer; I don't feel as overwhelmed.