New RN on med-surg floor

RNsRWe, ASN, RN · Sep 6, 2008

Probably not exactly what you're looking for, but each nurse gave you a different answer because there's lots of ways to skin the same cat, so to speak. YOU have to develop what works for you!

I do a quick assessment on each patient and address any emergent issues right after getting report. I move as quickly as I can through my patient load, checking on each one (because, frankly, sometimes they DON'T look like what I was told in report). I check for unexpected status, states of dressings and drains, IVFs, O2 situation, and if they're in pain right this second. Once I've moved through everyone, I go back to the ones I've prioritized as needing me first, and do a more complete assessment: v/s, lungs, bellies, skin issues. Give meds to get out of the way as appropriate. Then move to the next. By the time I've gone through THIS round, everyone is in top shape, everyone's medicated, and I know the status of everyone and what's coming next (or, as best as I can figure!).

I do it this way because I can catch any "OMG" moments pretty fast. And once I've seen them for myself, I know if my report is accurate enough to work off of, or if I've been fed a load of cr@p and I need to get cracking on checking, meds, dressings, charting.

That said, there are still plenty of shifts where I'm working on patient #2 out of 6 and all heck is breaking loose, and I don't GET to patient #6 until 1.5 hours or more after I've started! Not ideal, but we do what we have to to be as efficient as possible, keep everyone stable, etc.

Best of luck to you, and welcome to the crazy world of m/s!

RNperdiem, RN · Sep 6, 2008

I like to do the full head to toe, chart everything and move on to the next person. A focused assesment, to me looks like more work because you have to go back and fill in all the blanks.

There are so many interruptions in med surg that I like to do the full assessment all one time have it all charted and cross it off my list. Once all my assessments are done and the first rounds of meds are passed, my day has passed a milestone.

jogimada · Sep 7, 2008

Thanks. I really enjoy hearing how others do things. I am sure that I will get my own routine when I start working,buti do find it very helpful hearing from experienced nurses. Thank you for sharing.

mcknis · Sep 9, 2008

You def have to get your own routine down. I am 2 days til I am out of orientation and I am still trying to get my routine down.

Once report is finished I go and do my assessments on all pts (very quickly). I will then go check labs in case i have to call the doc on something. Give 0800 insulins and any 0700 & 0800 meds. Chart assessments and go give 1000 meds. During report I do keep a sticky note handy in order to mark down things I have to do. I lose track of time very easily in med-surg so i always have a note pad available to mark things down. i am the sticky pad king!

Things get crossed off as i am do them, and I keep track of what needs done now, later, and who cares if it gets done. makes things easy and able to be passed off at report. About the sticky pads, any labs that are abnormal are written down on a sticky sheet and passed off at report, saves time when giving report and the other nurses are grateful.

imanedrn · Sep 16, 2008

Here's my routine (with 6 pts). One MAJOR thing I've learned though is that your routine MUST be fluid and open to adjustment. When I first started, I wanted all of my "routine" to fit into a nice, neat, timely package. This would stress me out to no end when x'o'clock rolled around and X set of expectations (that I had for myself were not complete). So here's what works for me now:

0630-0700: arrive on unit, review Kardex, get general idea of pts
0700-0730: get report from night nurse & do chart check together
0730-0800: review chart to make sure nothing was missed; review AM labs; print all labs & procedure results to place in pt's bedside clipboard (I do this partly for myself and partly for the docs to make it easy to see everything, instead of having to look through the BIG chart or the computer)
0800-0900: initial assessment of all pts (in order of acuity based on info I received from night nurse), find out what their immediate needs are, answer any questions that I am able to immediately OR let them know I will follow up after med pass, let them know what the plan of care for today is, review 0800 VS (note: initial assessment is primarily focused on system(s) that is reason for visit, but I review entire body systems as well)
0900-1000: pass 0900 meds
1000-1200: deal w/ immediate pt issues noted during initial assessment (I used to chart all my initial assessments during this time period & would let almost nothing interfere with this; I realized I was neglecting some important pt interactions, so I changed this around...)
1200-1400: 1200 physical & pain reassessments, pass meds, do accucheks
1400-1500: lunch (I take 30-60 mins for lunch; unlike other nurses, I believe I deserve the time that's owed to me; since I pee only a couple times during my shift and NEVER take breaks, I make sure I get to relax and refocus myself during my lunch period, as well as enjoying my food and actually having time to digest it!)
1500-1700: nursing tasks (i.e., dressing changes), pass meds, do accucheks, and charting!
1600: physical & pain reassessments & chart them
1700-1800: final med pass, make sure pt's needs are cared for so I can do shift change w/o interruption, make sure they know that only immediate needs will be cared for during shift change (i.e., chest pain vs. needing more ice)
1800-1900: pull charts, make sure all meds & orders are in the system, sign charts, final check on pts
1900-1930: report & chart check
1930...: assist w/ anything that I didn't complete during my shift that I should have / am willing to help night shift with (i.e., IV that went bad at last minute, brand new admit, pt d/c's on my shift that didn't have ride until around 1900 hrs)

Although there are some time frames I stick to strictly (i.e., passing meds when they are due, doing nursing tasks later in the shift), most of the days' tasks are pretty fluid.

If I'm getting a lot of orders, I review the charts throughout the shift (not just at the end) to make sure that nothing was missed.

I also make sure to communicate w/ my pts & their families frequently throughout the shift -- even if it means I have to stop charting :angryfire temporarily.

I've also learned how to tell pts/families NO, when it's necessary. When I first started, I would jump EVERY SINGLE TIME I was asked for something. This resulted in lots of INEFFICIENT task doing. Now, I've learned to group things together. "You need more ice? Ok, give me a few minutes, and I'll get that along with my other 5 pts wants" (but in a much less sarcastic way).

I think the core of floor nursing (aside from the obvious patient safety) is time management. That is usually the hardest part for new nurses, and I think it directly contributes to burn out and feeling like nursing "isn't for me." In reality, the stress is overwhelming these nurses so much, that they don't have the chance to step back and take a good look at the big picture.

Unfortunately, it is VERY difficult to teach time management. I know some experienced nurses who regularly stay 2-3 hrs late to finish charting! That baffles me -- esp. that mgmt lets them get away with it! In any case, it's always good to find someone who's work you admire and see if you can work more closely with that/those nurse(s). I've found a few nurses who I admire greatly. None were my preceptor (who I rarely speak to anymore), but I find a lot to aspire to in the way they do things.

Good luck -- and, please, don't give up! :nurse:

jogimada · Sep 16, 2008

Here's my routine (with 6 pts). One MAJOR thing I've learned though is that your routine MUST be fluid and open to adjustment. When I first started, I wanted all of my "routine" to fit into a nice, neat, timely package. This would stress me out to no end when x'o'clock rolled around and X set of expectations (that I had for myself were not complete). So here's what works for me now:
0630-0700: arrive on unit, review Kardex, get general idea of pts
0700-0730: get report from night nurse & do chart check together
0730-0800: review chart to make sure nothing was missed; review AM labs; print all labs & procedure results to place in pt's bedside clipboard (I do this partly for myself and partly for the docs to make it easy to see everything, instead of having to look through the BIG chart or the computer)
0800-0900: initial assessment of all pts (in order of acuity based on info I received from night nurse), find out what their immediate needs are, answer any questions that I am able to immediately OR let them know I will follow up after med pass, let them know what the plan of care for today is, review 0800 VS (note: initial assessment is primarily focused on system(s) that is reason for visit, but I review entire body systems as well)
0900-1000: pass 0900 meds
1000-1200: deal w/ immediate pt issues noted during initial assessment (I used to chart all my initial assessments during this time period & would let almost nothing interfere with this; I realized I was neglecting some important pt interactions, so I changed this around...)
1200-1400: 1200 physical & pain reassessments, pass meds, do accucheks
1400-1500: lunch (I take 30-60 mins for lunch; unlike other nurses, I believe I deserve the time that's owed to me; since I pee only a couple times during my shift and NEVER take breaks, I make sure I get to relax and refocus myself during my lunch period, as well as enjoying my food and actually having time to digest it!)
1500-1700: nursing tasks (i.e., dressing changes), pass meds, do accucheks, and charting!
1600: physical & pain reassessments & chart them
1700-1800: final med pass, make sure pt's needs are cared for so I can do shift change w/o interruption, make sure they know that only immediate needs will be cared for during shift change (i.e., chest pain vs. needing more ice)
1800-1900: pull charts, make sure all meds & orders are in the system, sign charts, final check on pts
1900-1930: report & chart check
1930...: assist w/ anything that I didn't complete during my shift that I should have / am willing to help night shift with (i.e., IV that went bad at last minute, brand new admit, pt d/c's on my shift that didn't have ride until around 1900 hrs)
Although there are some time frames I stick to strictly (i.e., passing meds when they are due, doing nursing tasks later in the shift), most of the days' tasks are pretty fluid.
If I'm getting a lot of orders, I review the charts throughout the shift (not just at the end) to make sure that nothing was missed.
I also make sure to communicate w/ my pts & their families frequently throughout the shift -- even if it means I have to stop charting :angryfire temporarily.
I've also learned how to tell pts/families NO, when it's necessary. When I first started, I would jump EVERY SINGLE TIME I was asked for something. This resulted in lots of INEFFICIENT task doing. Now, I've learned to group things together. "You need more ice? Ok, give me a few minutes, and I'll get that along with my other 5 pts wants" (but in a much less sarcastic way).
I think the core of floor nursing (aside from the obvious patient safety) is time management. That is usually the hardest part for new nurses, and I think it directly contributes to burn out and feeling like nursing "isn't for me." In reality, the stress is overwhelming these nurses so much, that they don't have the chance to step back and take a good look at the big picture.
Unfortunately, it is VERY difficult to teach time management. I know some experienced nurses who regularly stay 2-3 hrs late to finish charting! That baffles me -- esp. that mgmt lets them get away with it! In any case, it's always good to find someone who's work you admire and see if you can work more closely with that/those nurse(s). I've found a few nurses who I admire greatly. None were my preceptor (who I rarely speak to anymore), but I find a lot to aspire to in the way they do things.
Good luck -- and, please, don't give up!

Thank you for sharing all of this information! I start my new job on Monday, and I will definately refer to your advice, and all of the other advice given in this thread. Everyone has been so helpful and willing to offer advice/tips and I just love this site! I am so thankful to have this site and fellow nurses to help answer questions. I've learned so much and have been comforted and educated hearing from other nurses who have contributed their advice, knowledge, etc.

Thanks!!!

DLS_PMHNP, MSN, RN, NP · Sep 17, 2008

Probably not exactly what you're looking for, but each nurse gave you a different answer because there's lots of ways to skin the same cat, so to speak. YOU have to develop what works for you!
I do a quick assessment on each patient and address any emergent issues right after getting report. I move as quickly as I can through my patient load, checking on each one (because, frankly, sometimes they DON'T look like what I was told in report). I check for unexpected status, states of dressings and drains, IVFs, O2 situation, and if they're in pain right this second. Once I've moved through everyone, I go back to the ones I've prioritized as needing me first, and do a more complete assessment: v/s, lungs, bellies, skin issues. Give meds to get out of the way as appropriate. Then move to the next. By the time I've gone through THIS round, everyone is in top shape, everyone's medicated, and I know the status of everyone and what's coming next (or, as best as I can figure!).
I do it this way because I can catch any "OMG" moments pretty fast. And once I've seen them for myself, I know if my report is accurate enough to work off of, or if I've been fed a load of cr@p and I need to get cracking on checking, meds, dressings, charting.
That said, there are still plenty of shifts where I'm working on patient #2 out of 6 and all heck is breaking loose, and I don't GET to patient #6 until 1.5 hours or more after I've started! Not ideal, but we do what we have to to be as efficient as possible, keep everyone stable, etc.
Best of luck to you, and welcome to the crazy world of m/s!

Thanks, that is a very helpful and informative post :)

imanedrn · Sep 17, 2008

Thank you for sharing all of this information! I start my new job on Monday, and I will definately refer to your advice, and all of the other advice given in this thread. Everyone has been so helpful and willing to offer advice/tips and I just love this site! I am so thankful to have this site and fellow nurses to help answer questions. I've learned so much and have been comforted and educated hearing from other nurses who have contributed their advice, knowledge, etc.
Thanks!!!

Just make sure you take all of the and find what works for YOU. After some exposure, you will realize that every single nurse does things slightly differently -- though all to the same end. As I mentioned, there are some experienced nurses who regularly stay late to chart -- and mgmt does nothing about this! :banghead: So clearly there are some people that never get it. The whole point, however, is to find what works for YOU, so you don't end up like THEM. :no:

I think I mentioned this previously, but it's worth repeating, find one or a few nurses with whom you work that you admire (and, of course, are willing to share their wisdom with you) and see if you can model some of your routine, tasks, behaviors, patient interactions, etc. after theirs. As I mentioned, I got more from a few other nurses than I ever did from my preceptor. And I will continue to do this for AT LEAST the first 5 years of my nursing career (assuming I stay in med/surg). I will also continue doing this if/when I change departments -- every single time. Nursing is too important to EVER think that you've mastered it all. I admire veteran nurses who willingly admit that they're always learning new things or ways to do things. To me, that's a GOOD nurse!

Nursing is such an OJT (on the job training) field that it helps way more to have good, safe, experienced nurses to refer to than referring to any stack of textbooks ever will!

I know some of that was a slight digression, but I think it all fits into that big picture of finding your "routine." Just following a schedule will let you down every time. The nursing professional requires human interaction to be successful, and I believe that's the BEST way to become a GREAT nurse!

litbitblack, ASN, RN · Sep 18, 2008

I generally after report check my mars and see what meds I have due immediately. I can assess the ones that first meds first. only takes 5 min to do a head to toe assess. then am meds, assess them while they are taking their meds. you can generally assess while your talking to them. combine your med pass if able to instead of going in at 12 1 and 2 you can do 1230 and 1330. it is usually little things that can cause your day to be off. try to control your day and not let it control you. notice i said try lol