New to med/surg nurse needs help with "plan" part of adpie

[gatoraims RN]

I am a new to med/surg nurse but not new to nursing. I am still in orientation and my preceptors all say I am doing a great job. However I am not as confidant. I see other nurses just running circles around me. Currently I want to work on the plan for my patients.

During shift handoff I am lost more times than not of what the plan for a patients is. How do I make myself better with this. Some issues I can come up with a plan like a pt with a PICC who needs IV atb, he will remain in hospital until the IV atb is complete.

But the 98 year old chf pt who is now able to oxygenate better and is currently tolerating his lasix well. I myself am not sure why he is still in the hospital when the reasons he was hospitalized are under control. The hospice consult was refused by the family and the plan on sending him back to his skilled nursing facility. How do I answer or know what the plan is.

Or the pt who was admitted for abdominal pain, CT was negative, stools negative, labs normal. She is still in pain but generalized and not just abdominal. The generalized pain is chronic pain. Md is aware of pain issues but she has had chronic pain for years and medication is not helping. I could say pain control but I still think there should be more. I feel like such an idiot that cannot give a good report or know what the plan for my pts is.

Thanks for any tips.

[ClaraRedheart, BSN, RN]

Are you on days or nights? In the facility that I work at, we have "Clinical Nurse Facilitators" that manage our patient's transitions. These nurses usually help with cases in which a patient can't go home and needs to go to a SNF, LTAC or rehab. In the notes section of our charting software, they usually have very detailed notes. If I have time, I like to read through them and write down the highlights on my "brain" so when morning comes, I can give a good report. Also, our MD's usually have a format to their notes where they detail their plan on the last paragraph. I like to write down those highlights too and make sure that I am addressing what I can of their plan during my shift. During my end of care note, that helps me to know what to highlight has been going better/didn't work for each patient. An example for this would be where a patient has been on IV pain meds because of acute pain and needs to transition to oral so they can manage the pain at home. The physicians need to know how the patient tolerates oral pain meds and how their pain scale has fluctuated on it... did they have nausea with the oral pain meds, etc.

[Momma1RN, MSN, RN, APRN]

It can take a few months to get familiar with the flow of med/surg. Sometimes it's not so cut-and-dry why patients have not been discharged. My hospital is actually doing some internal research on why our CHF patients have such long stays, because like you said, many times they are there for longer than it SEEMS they need to (weaned off O2, no SOB/DOE, lasix therapeutic, kidney function WNL, etc.). I know at my hospital patients are notorious for saying to docs "I feel better but can i just stay one more day?" and docs have a hard time saying no. My plan is always "well so and so is flagged for discharge and I don't see any reason why they're not ready to go home, but it's up for the doctor to decide". A lot of times it's out of our hands- we can of course advocate for the patients, and docs will often listen to us if we try and convince them the patient is ready and wanting to go home.