New Grad subacute help and advice please

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Hi,

I have been on allnurses a long time. Normally I can find answers to what I am looking for without typing a post, I think this might be my first post.

I just accepted my first nursing job and I am very excited but when I got home and thought about it I started getting nervous. In my preceptorship I took care of 4 patients and now I am going to have 30 residents that are fresh from the hospital and more acute then the rest of the residents at this facility. I am only getting 5 days before I am on my own. I am wondering how do you guys do it? 30 patients?

I was told there is a treatment nurse so I think I do meds and charting and I'm not sure would I do head to toe assessments? On 30 patients.

Thank you, and I would really appreciate any advice at all on this and working at a skilled nursing home in general. Like a typical day, and how to delegate to CNA's.

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Specializes in Critical Care, Education.

Congratulations on your new job.

One of the biggest shortcomings in our (US) nursing education curriculum is the overwhelming focus on acute care settings. Our new grads don't have a very clear understanding of how nursing 'works' in other settings. If you're looking at a 30 patient assignment with your acute care 'glasses' on, it appears to be absolutely impossible. But the care routines and schedules are different in sub-acute settings. Take assessments for instance - a full assessment each shift is a 'must' in acute care.... not so much in other settings. VS Q 4 hours? Nope. In non-acute settings, most of the physical work of nursing is focused upon ADLs, so it can be delegated to non-licensed staff. Your role will be very different.

Use that orientation period to learn as much as you can about the normal routines and processes. Find out how your preceptor organizes his/her shift and see if it works for you. Based on my experience, one of your biggest challenges may be team leading since nursing schools typically don't devote much time to this important skill. You'll need to learn how to effectively delegate and supervise your team so that you can work together to provide great nursing care. This may take a while.

Don't worry. Don't try to apply acute care standards and processes. You can do this. You'll be fine.

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Thank you so much for the advice and encouragement! I really appreciate it! It's true in school I only got acute care so I'm thinking of it that way. I don't know any nurses personally and I'm the first one in my class to take an rn job so I have no one whos been there in my life to ask. And it's scary not knowing what to expect si thank you!

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Time management is king...remember, the residents in subacute are not your friends. There's no need to schmooze with the same person for hours. Pass the medications, change their dressings, and quickly move on.

Creating a to-do list helped me stay somewhat organized. Here's an old to-do list with names changed due to HIPAA. I worked on a rehab unit at a large rehab/SNF several years ago and here is how I used to organize for the day. I worked 16 hour weekend double shifts from 6am to 10pm.

I normally had about 15 patients to care for. At the beginning of the shift I would look through the MARs and TARs and, as I went, I jotted down the tasks that needed to be done in my notebook. My to-do list in my notebook was how I organized my shift, and as a result, I wouldn't forget to do anything.

9-23-20XX

DIABETICS, FINGER STICKS: Agnes (BID), Norma (AC & HS), Bill (AC & HS), Pauline (AC & HS), Rex (BID), Jack (BID), Ethel (AC & HS), Marjorie (0600, 1200, 1800, 2400)

NEBULIZERS: Marjorie, Ethel, Bill, Jack, Pauline

DRESSING CHANGES: Pauline, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Pauline (Vancomycin), Agnes (Flagyl), Rex (ProcAlamine)

COUMADIN: Agnes, Rose, John, Lucille

INJECTIONS: Agnes (lovenox), Lillian (arixtra), Rex (heparin), Bill (70/30 insulin), Ethel (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Pauline (wound infection), Rose (UTI), Rex (pneumonia),

1200, 1300, 1400 meds: Marjorie, Lillian, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura, Louise

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Norma's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

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TheCommuter--Super advice! Exactly what I would have posted.

blindcheeseit--First, it seems you will be working in a skilled facility(?) It may depend where you are, but back in Florida sub-acute is pretty much trauma-center step-down or community hospital ICU: trachs, vents, tele, GTubes/JTubes, central and/or peripheral lines, blood transfusions, TPN, Foleys, wound vacs, patients are sedated or immobile--and you might have all these on several patients in an assignment, while your "light" patients are merely semi-comatose post-CVAs or stable head injuries who require total care but aren't able to buck the vent (AKA--ventilated patient's call bell) fall out of bed, or pull anything out. Skilled facilities tend to have more stable, if generally more demanding, patients. If it IS a true sub-acute type floor and they expect you to handle 30 current or recent train-wrecks, get out NOW.

Having done the only-nurse-for-30-plus-skilled-patients thing, I'll reiterate that organization and prioritization are key elements. The other major asset you will have is good CNAs who can provide excellent care with minimal supervision; these people are not always easy to find, so when you do find them, treat them like GOLD because that's what they are worth. Never be too busy to help your CNAs if they really need it, but you also can't be afraid to delegate. However, always ask for your CNAs' input and advice and take it--when I was a brand-new RN on a peds floor, the best "nurse" on the unit was a CNA who had been there since, I think, time began: she taught me half of what I know about sick kids, and good LPNs taught me much of the rest. Say Please and Thank You, and offer to help whenever you can--in this world, you get what you give.

Finally, never be afraid to ask for help whenever you need it. If you have a supervisor or nurse on another unit or hall to use as a resource, do just that. And don't expect to get the hang of it right away: almost certainly you will spend the first few shifts on your own feeling like you've been set adrift on a raging sea with only a pair of kid-sized water wings to hold you up--this is normal. Focus on what MUST be done RIGHT NOW and who exactly needs you the MOST--everything else can wait until you can stomp out the biggest fires first.

Good luck, and congrats--you can do this, others have done it--you will survive! :yes:

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Thank you! I think my sub acute is just like a skilled nursing home. The DON did say I have a supervisor they review labs and call the doctor. Then there is a treatment nurse. So maybe I just do meds, for 30 patients...

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Specializes in Pediatrics, Emergency, Trauma.
Time management is king...remember, the residents in subacute are not your friends. There's no need to schmooze with the same person for hours. Pass the medications, change their dressings, and quickly move on.

Creating a to-do list helped me stay somewhat organized. Here's an old to-do list with names changed due to HIPAA. I worked on a rehab unit at a large rehab/SNF several years ago and here is how I used to organize for the day. I worked 16 hour weekend double shifts from 6am to 10pm.

I normally had about 15 patients to care for. At the beginning of the shift I would look through the MARs and TARs and, as I went, I jotted down the tasks that needed to be done in my notebook. My to-do list in my notebook was how I organized my shift, and as a result, I wouldn't forget to do anything.

9-23-20XX

DIABETICS, FINGER STICKS: Agnes (BID), Norma (AC & HS), Bill (AC & HS), Pauline (AC & HS), Rex (BID), Jack (BID), Ethel (AC & HS), Marjorie (0600, 1200, 1800, 2400)

NEBULIZERS: Marjorie, Ethel, Bill, Jack, Pauline

DRESSING CHANGES: Pauline, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Pauline (Vancomycin), Agnes (Flagyl), Rex (ProcAlamine)

COUMADIN: Agnes, Rose, John, Lucille

INJECTIONS: Agnes (lovenox), Lillian (arixtra), Rex (heparin), Bill (70/30 insulin), Ethel (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Pauline (wound infection), Rose (UTI), Rex (pneumonia),

1200, 1300, 1400 meds: Marjorie, Lillian, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura, Louise

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Norma's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

I had a similar "brain" sheet I used when I worked in subacute.

The best thing is you will learn A LOT; you will also learn to keenly assess a patient without a lot of technology, rely on a old fashioned assessment, and with the kind term rapport focus on care plans and see the bruising process in action (that's not to day in acute care you don't, it's just different. ;) )

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