New Grad making small mistakes!!!

[DH1234]

I am on my 7th week of orientation, and I am finally taking a full pt load meaning 4-5 patients. And I am not going to lie it has been hard to keep up. With that said I have trouble keeping up with the small things that are actually really important. For instance, two of my patients where Turn q 2. And I totally forgot one patient was Turn q 2, and I did not document anything. She kind of shifts independently in bed and had no skin breakdown, but I know that does not matter because she was at risk according to the Braden scale and per hospital policy that makes her a turn. My other patient I remembered who was a turn I would be busy with other patients so it would take me like 3 hours before I can get back in there to turn her. I like documenting my turns in real time, but I know a lot of nurses back chart it to make sure it shows that they were turned q 2 hours exactly even if it took them longer. I get paranoid about doing that because I am not sure if that is consider false documentation. Also, the aids usually handle the turns for the most part, and sometimes I assumed she would go in there and do the next turn but she never did, which once again that is also my fault for the lack of communication.

Now I am freaking out that I can get written up or lose my job over these mistakes. Also, any advice on how to keep up with turns on your busy days.

[CalicoKitty, BSN, MSN, RN]

Q2 turning is something that can be worked out with your techs, such as nurse/tech being expected to do alternating q2 turns - say tech at 8, nurse at 10 (with meds), tech at 12 (with meal set up), nurse at 2 (with meds!). Some patients obviously require several people to reposition.

Documenting something that wasn't done is false documentation, but back documenting happens as not everything can always be charted "in real time". Who is responsible for documenting the turn if the tech does it?

I'm not positive how documenting at 2pm (the default time column) something that happened at 2:30 (time performed) is addressed. Also, not sure if q2 turning has the window such as 1 hr before/after for other tasks (like meds).

[Forest2]

REALITY ALERT!?

1)There will be nurses who do not turn patients and don't intend to but chart that they do.

2)There are also nurses who don't turn exactly like they are supposed to but still chart that they do.

3)Then there are nurses that do everything they can in order to turn patients, but maybe can't get there in time or miss one here and there, yes, they chart they do them timely too.

I know there will be some that don't like this but it's the truth in my experience of over 30 years and the truth is not always easy to hear or to read about. When shifts are slower or the unit is good, you will have time to follow the turn requirements and chart it.

As a new nurse you are learning the about real world of nursing and how to take care of patients and follow the policies too. The discouraging part is you can't always do it all. It would not surprise me if other nurses were having the same problem but not admitting it, maybe you aren't alone.

My recommendation is when you have documentation questions go and check the policy, if there is no specific policy then ask your supervisor. Be sure to make yourself a note about who you talked to and what they said. Keep in mind that what you are told may not be entirely accurate. I always chart real time because this was how I was taught and it makes the most sense to me. You can turn a patient more often if you want to. If you are in the room already but are an hour early or so, go ahead and turn them at that time, then reset for 2 hours. There is no shame in asking for help if you get behind. You are still in orientation so this is the perfect time to ask questions and let your preceptor know where you are struggling.

You are a conscientious nurse and this is a good quality to have. You are still learning to adjust to the real world of nursing, so try not to freak out too much. One thing about nursing, it is a fear inducing job for sure. Good luck.

[Forest2]

12 minutes ago, CalicoKitty said:

Q2 turning is something that can be worked out with your techs, such as nurse/tech being expected to do alternating q2 turns - say tech at 8, nurse at 10 (with meds), tech at 12 (with meal set up), nurse at 2 (with meds!). Some patients obviously require several people to reposition.

Documenting something that wasn't done is false documentation, but back documenting happens as not everything can always be charted "in real time". Who is responsible for documenting the turn if the tech does it?

I'm not positive how documenting at 2pm (the default time column) something that happened at 2:30 (time performed) is addressed. Also, not sure if q2 turning has the window such as 1 hr before/after for other tasks (like meds).

That's right Kitty, I should have mentioned sharing the duty, like you get them now and I will get them later, or take you take this room this shift and I will get the other guy. I've done that but forgot to mention it. So happy I am not a new nurse these days.

[Crash_Cart]

1 hour ago, CalicoKitty said:

Who is responsible for documenting the turn if the tech does it?

Another case of the documentation process doesn't fit the real world reality of the matter.

Quite frankly I think the order to turn pt's on a specific schedule is just a form of micro-management in the first place. It's like writing an order for the nurse to empty the foley drainage bag whenever it becomes full.

Nurses are already acutely aware pt's need to be turned frequently to prevent skin breakdown, and they don't necessarily need any order telling them about the blatantly obvious.

[Forest2]

13 minutes ago, Crash_Cart said:

Another case of the documentation process doesn't fit the real world reality of the matter.

Quite frankly I think the order is just a form of micro-management in the first place. Nurses are already aware pt's need to be turned frequently to prevent skin breakdown and don't necessarily need any order telling them that.

That's true, it is standard nursing care. They probably add in the order, maybe it is prompted electronically from the scale or some such thing as that. You are right though that it really doesn't need an order, it is like having an order for "extra 2 blankets each shift prn patient complaint of feeling cold". LOL, yea, we know to do that.

[CalicoKitty, BSN, MSN, RN]

I know some hospitals are more "picky" about documenting the q2 turns, others just give reminders that patients are to be turned q2, but don't necessarily discuss documenting it real time (or q2 hours) - more of a note or plan of care documentation.

[beekee]

If a patient is shifting independently, I’ll pop my head in, note what side they are on and chart that as a turn. It doesn’t matter who does it.

[mmc51264, BSN, MSN, RN]

we have to do safety/rounding checks every 2 hours and being on an ortho floor, lots of pain assessments/re-assessments. I chart in the room when I am there and make sure I do I&Os, pain, an my Q2H turns. Most of the aides I work with are great partners. While it may not be 2 hours on the hour at the stroke of the hour, we get pretty close and chart when we are in the room. It is not too difficult when you get used to it being part of my routine