New grad, please Help with med surg organization!!

Specialties Med-Surg

Updated:   Published

Ok. I just completed my first day on the floor. I feel horrible, there was no structure to the day, I was just thrown out there to care for five patients with my preceptor. I know my organizational skills are severely lacking because I have never cared for five patients. I feel like I will never get this, does anyone have any updated med surg worksheets?? I have reviewed some on the site, but was wondering if anyone out there has updated examples. Any advice or input would be helpful.

Specializes in Med-Surg, Geriatrics, Wound Care.

I have a brain (and a half) for working med-surg 12 hour shifts (7-7). The brain is 2 per page, double sided (if you print that way). I'm working on the 'cover' page so I can more readily keep up with stuff like who has meds/treatments and when without having to check each sheet. I tend to write small. I stick patient stickers on the corners. Phone numbers for the PCTs. The bottom is most of the admissions questions to ask so I don't have to drag the computer in with me. Good luck! Hope you are getting better with it.

FrontSheet.doc

MyPage2Per2sv4.doc

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PediLove2147,

I just wanted to tell you that I thankfully stumbled upon this thread and looked at the brain sheet you created and posted. I have been using it for the past 2 weeks or so and it has helped me out so much! I feel more organized with it and my report to the next shift seems to flow 10x better when I'm using it. I just wanted you to know that I've benefited from using it. Thanks again!!

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Specializes in Pediatric Cardiology.
Quote
PediLove2147,

I just wanted to tell you that I thankfully stumbled upon this thread and looked at the brain sheet you created and posted. I have been using it for the past 2 weeks or so and it has helped me out so much! I feel more organized with it and my report to the next shift seems to flow 10x better when I'm using it. I just wanted you to know that I've benefited from using it. Thanks again!!

I am so happy to hear that! I love my report sheet so I like hearing it's helped others as well! ?

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I am so happy to stumble on to this thread. I will possibly be moving to a surgical floor from a step down unit so all the sheets here are great resource and hopefully I will use in the future!

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Specializes in Oncology.

I would like to share what is on our "Report Sheet" or Structured handoff sheet. At the top, you include the Name,Age, Admit Date, Doctor, Hippa info, & Diagnosis. You need to know the patient's Past Medical History. You also will need to know their Allergies, as well as Isolation Type, Code Status, and what language they speak and their Height and Weight. Our sheets then follow the report by systems. This section starts with Neuro and a place to write in what their status is (AOX3 or "May have Confusion at nighttime"). Respiratory is next with lung sounds and any O2 or breathing treatments or Trach information. Next is Cardiac. You would include any information regarding the Cardiac status, such as murmurs or edema etc and any VTE prevention. After that is IV, site, and date, with IVF. GI system with ordered diet, Date of last BM, ? Ostomy, any Tube Feedings, and assessment of the GI system is included. You also want to cover the Urinary or GU with method of voiding, catheter information etc. A place for skin assessment and any treatments needed would be included. There should be a place for Procedures that were done this hospitalization. Included a place for VS and Lab results. Also include I&O. PRN medications and Pain Medications should be included. This should give you a good start. I am happy to say, we will be switching to EPIC very soon, which will have all that information included in the EMR with just a click and on one screen. I am so ready. I hope that helps.

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To the OP- One thing that I copied as a new grad from another RN was the idea of an hourly "to do" list/timeline in addition to the "brain sheet" (I incorporated it into my "brain" sheet). I would write in each hour for my shift (I work pms), and then fill in when meds or treatments were due for my current shift. Something like this...I would put the room number of the patient and an "X" by the room if they had more than one medication due at that time). Example below is an hourly example of a pm shift starting at 1500 (3 pm):

1500-Rm 222x, Rm 232x

1600-Rm 243

1700-Rm 222 accucheck

1800-Rm 222 TPN

1900-Rm 228x

2000-Dressing change Rm 222

2100-Rm 222x and accucheck, Rm 232x, Rm 243x, RM 252x

2200-Lab draw Rm 232

2300-

The beauty of this, was you are able to see where the bulk of your medpass is when the shift first starts and work around that. I would cross off the room number as I finished the med pass/treatment, etc. If there are certain hours in your shift where there are few meds/treatments, you can utilize this to plan for as needed tasks that you hope to complete...i.e. ambulating a patient, some teaching you want to do, maybe a PICC line dressing change is due, or whatever else needs to be done. You're working around med times, but also can write in reminders such as if you need to check the result of a lab draw (ie. a vanco level, etc) or a timed draw, etc. I found it very helpful to keep me on track, especially when there are so many distractions.

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I am so happy to have stumbled on this thread. My aunts are nurses and have suggested that i begin in med/surg and I feel that my neurotic personality will fit one I am done with nursing school. This info is very helpful. thank you!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Everyone needs a good brain sheet.......here are a few.

horshiftsheet.doc

5 Pt. Shift.doc

FinalGraduateShiftReport.doc

1 patient Float.doc

MTPMedSurg (2).doc

Report Sheet (1).doc

DAY SHEET 2 doc (1).doc

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Great post!

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PediLove2147 said:
I'll share my "brain" because I created it myself and I am quite proud of it! :smug:

There is a lot to it but it keeps me organized.

I am a brand new nurse, what does svc mean on your brain sheet? I really appreciate your help. I am very happy that I found your sheet.

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Hi, I know it is hard when you first start out, this is what I do, I use a separate brain sheet for each patient, so if you have 5 patients I print out 5 sheets. It is also difficult with a preceptor because the way she does things might be different then the way you do things. a little advice with medical surgical nursing that has really helped me, go to the most critical patients first and do the most critical tasks first, i.e. giving blood, hooking someone up to telemetry, they tell you to prioritize in nursing school and that is really true, that is the key I think, but there is always stuff you will have to learn as you go, and sometimes you will just feel like your day is a disaster, at least I do sometimes lol, maybe it's just me....here is a brain sheet that looks really good

https://www.pinterest.com/pin/373658100305612758/

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I too am having a hard time getting organized... My hospital does bedside shift report and it starts at 6:45-7 and last 7:30-8.. So there is no time to get organized... The best day I've has so far is because I came in an hour early and worked off the clock for free... My preceptor does this and looks at me like I'm late if I get there at 630... And as soon as we're done she says to start meds, she makes me give all 9-10 meds starting at 730, so any advice on organizing my day when it seems like you start out an hour behind???

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