Nursing Residency: Stick to a Plan

[chemshark, BSN, LVN, RN]

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This week, I assumed full care for 2 patients. The only time that my preceptor would come inside the rooms were to introduce herself to the patients, watch me give meds, and hang antibiotic infusions or give blood and other procedures. "It's about time that you started picking up your own patients," she said. This took me aback because I was waiting for her to tell me that I could do so.

It feels different to fly solo. I explain to my patients that I am a student nurse and the preceptor will step in to help but that I would be their main contact. Even when patients are sick, I see that they only believe me if I believe in what I'm saying myself. I'm patient, though. I assume this will come in time.

0630-0730: Every morning, I try to have a plan. It's more like a timeline, really. I come in, change into scrubs, say hi, then grab the patient assignment list and a blank kardex. If I have been gone longer than two days, I tend to not have any repeat patients so I go straight into the chart and read up on their H&P. Unfortunately, I can't access new orders (very frustrating) but I am notified that there are new ones. My preceptor clears them all for me and lets me know if there are any pertaining procedures for today that involves a road trip. If so, I make space on my kardex for tasks to be done. I get the report from the offgoing nurse--I don't want them to wait longer so I try to be ready when they call my name. I try not to interrupt, but if there's something pertinent that I didn't read on the chart such as a change in diet or a consult from surgery or wherever I ask questions. I try to have the handoff at the patients bedside and I inspect my lines while the nurse is talking to make sure they are secure and patent and that they are the right gauge as on the flowsheet. I don't do my general exam just yet but I inspect the particular site that the patient's chief complaint is about. I.e. most of our transfers are from surgery, ICU, or the ED. Therefore, if someone is here with laparoscopic incisions or I saw that they had >900 BNP then I quickly do a focused exam with the nurse there so she can tell me if something is different or new. Once they leave, then I go back into the chart and list the medications for the day. I try to give the meds within an hour pre and post of the given timeline. If it says, 'daily' then I am allowed to reschedule the med to when it is convenient for me. I can't do that with qhourly meds but it is good to be able to aggregate them together so I don't have to keep going back and forth. It is these little tricks that save me time during the morning rush. After writing the meds, then I look them up quickly so I know what I'm giving and why. The computer system in the Navy isn't as fast as EPIC so I can't bring up LEXICON at the patient's bedside. I have to prepare ahead of time so I don't look like a fool. Next I talk to my Corpsman and we work out an agenda for the day so that we don't waste time doing things redundantly. He or she knows that I will let her do the vitals and strict I&Os for me but if something is abnormal then he must notify me so that I can get the vitals for myself. They can clear my infusion pumps but I need to know how much fluid my cardiac patients are getting because we have to observe how closely they diurese lest they cancel their discharge plan because I'm not charting accurately. I also let them know if I am expecting my patients to make a trip to imaging, the OR, CATH LAB, or if the PT is going to visit today. This way, I can ensure that my patients have been NPO, have had their vitals and samples taken prior to the road trip.

0800-0900: Okay, so now I go back to each of my patients and systematically do a general exam. This is quick, usually takes 5-10 minutes. If they are a concern for something else, then I add an extra few minutes listening to murmurs, ascites, or evaluating their strength and neurological status. Those who are immobile or have respiratory conditions I have to ask my Corpsman to help me turn so I can listen to their lungs while I look at the Mepilex on their butt so I can stage the wound. My preceptor expects this to be done because she just wants to walk in and concur or disagree with my findings. She will let me chart what I see but she will add a new note if it differs from what I wrote. I like that she lets me record my own opinions and assessments (for the most part). Next I inspect and palpate the PIVs and flush them to make sure that they are still viable. Then if there are continuous infusions I verify the bag and orders and check the Alaris. There should be tags on the bags and labels on the lines so that we know when to change them since lines are only allowed to be used for one day if they are intermittent and four days if they are continuous. Then I go over the plan of care with the patient and chat a little bit. This is when I evaluate their pain levels and I discuss pain management and other education with them. I am also charting my full assessment at this time. I do this for all my patients then I run back to the Pixies.

0900-1200: I pull meds for only one patient at a time. If they are on antibiotics or any other intermittent infusions, I check online to make sure that the meds I'm giving are compatible. If I have a question, I call the pharmacy--though they're not always helpful. Sometimes I have to be resourceful: if the order calls for 1500 mL D5NS and I only have 1000 then I label the bags with my date, time, initials, rate, type of fluid, then I write "bag 1/2, where bag 2 to infuse 500 mL only" so that if it is still running at the end of the shift, the other nurse knows exactly what I'm doing. Otherwise, sending the Corpsman to pick up a bag of 500 mL would take too long and I'd miss my deadlines. If the medication is Novolog or Enoxeparin I make sure that the Corpsman has done the BS and that the food tray is on the ward. Then I give the med or watch the patient do it so I can annotate that I educated the patient. If it is a controlled med such as Morphine or any other Norco, then I make sure there are stool softeners in the morning meds. My preceptor makes sure that I also input the exact time of when I administered the Morphine so that they don't overlap. And if I am giving meds with parameters, I take the vitals before giving it to the patients such as pulse for Lovenox, PT/INR for Warfarin, as well as B/Ps for -sartans, -pines, -lols, and -arbs. An additional complication is when a patient is on lidocaine patches. Since these are only to be given q12, if the patient decides to restart taking it, then I have to readjust the orders in the chart so that the q12 countdown begins again. Then I have to remember to write "remove" 12 hours from when I placed it on the patient so that the night nurse will know to take it off otherwise the patient will forget. Then I have to place it in a special bio container.

Antibiotics are complicated to, because when I was preparing them for my nurse, the pharmacy or the docs made a mistake on the order and it was actually supposed to infuse for 4 hours, not 30 minutes. So we had to write an annotation on that and an incident report but luckily the patient didn't get that infusion and we were able to backtrack everything and start over. Thank goodness that there is a policy where if the doctor or pharmacist wants to talk to me and my Corpsman answers the phone, they must refuse to take a message and insist that they speak directly to me so that nothing gets lost in translation.

1300-1330: I take lunch. I have to bring my own salad because the food sucks here and we don't have time to leave the floor anyway.

:

1330-1700: I start prepping my patients for their surgeries. I coordinate with the OR and we discuss the best time to transport. Then I let my Corpsman know so that he can get all his vitals and I/Os done on the other patients before he wheels my surgery patients out. I continue to take care of my remaining patients and help out with my preceptor's patients while keeping an eye out on the surgical patient's location and status.

At this time, the charge usually flags me down and notifies us which patients we are expecting to recieve. I read on their history, and get the telephone handoff report from the nurse. I can't do this on my own so my preceptor takes the report and I listen on the other line. She asks all the relevant questions needed especially on what brought the patient here and what medications need to be continued during their stay on med/surg. If they are on trachs, or PICC lines, and what interventions still need to be done. Finally, if there are bed sores or fall/seizure precautions that we should be aware of. If there are medical interventions that my preceptor isn't familiar with, she drills the nurse and asks for the rationale. She does not accept when the ICU or ED nurse does not understand why the patient is getting certain treatments. She wants to hear it from their mouths or at least have the contact information of the specialist that she can talk to.

There are five notes that must be completed before I am allowed to accept patients and they are: 24 Hour Nursing Note; a completed Admissions History Note; Medical Requisition Note; Admissions Assessment; and ED/ICU Transfer Note. They must be signed by the nurse, intern/resident (both), or the attending otherwise they are not legally viable and we will refuse transfer. Badgering the nurse/intern to get it done works.

Since I care for the somewhat stable patients, they are usually on their way to be discharged. Before my admit comes in and while my other patients are in surgery, I prepare the other patients for discharge: I take their last vitals and have the Corpsman d/c their PIV lines. I will d/c the PICC line on my own but if the patient has a thrombus, we insist that the physician is at bedside just in case anything happens. Then I check that the interns signed the Patient Discharge paperwork and I annotate my 24 Hour Nursing Note with the Assumed Care entry and start to populate the Multi Discharge Summary Note. I annotate the patient's status and that I have removed all lines, bands, and anything else invasive. Then my preceptor clears all orders and I wait until the D/C orders come through. Then I print two copies of the discharge teaching plan and highlight what is different, such as new or d/c'd home meds, upcoming appointments, and I take it to the patient's bedside after finding out when their ride will arrive. Once they are cleared and ready to go, I send the Corpsman to pick up the discharge meds from the pharmacy. Then I get it and go to the patient's bedside. My preceptor says nothing as I go through the paperwork with the patient one by one. I do my medication teaching and I provide the medication rationale and make sure that the patient can tell me when the next dose of their new medications are. If they have to d/c their home meds or continue it but with a different dose then I discuss that as well. If they have to give their own injections then I make sure I watch them do it. I go over their hospital summary and instruct them to show it to their PCP. Then I talk about their upcoming appointments and who to call if they don't hear from anybody in x amount of days. Finally, I address any questions they have and have them sign my copy while they keep their copy. I send them out with the Corpsman who wheels them to the quarterdeck. I notify the housekeeper to let her know that the room is ready to be cleaned and sanitized. Next I go back to my computer and continue to populate the flowsheets making sure that my I/Os, PIVs, and TXs are backdated. Then I open up the discharge note and make sure that my note times are in line so that there is no confusion. Finally I go back to the flowsheets and annotate that I discharged the patient on all the entries and that medications are all d/c'd so that no one else can come and make an entry later.

CONCLUSION: ...I still get overwhelmed. After the 12 hours I am physically tired but I no longer leave the hospital exhausted. I sleep a little better but I am still haven't gained the endurance for three 12 shifts in a row. It is just too much right now still.

I talk to Commander Jack when I am feeling overwhelmed. He always has an open door policy and stops everything that he's doing to talk to me. We discuss the difficulties of working with preceptors with very high expectations as well as the challenge of working in an institution that have unnecessary policies that slow things down and makes the work harder. He listens and empathizes with me. I always feel energized after talking with him.

Sometimes when Commander Jack isn't in his office, I draw on his whiteboard on his door. On this particular day, the Rear Admiral was going through the spaces for an inspection, haha. I hope he didn't get in trouble. She was actually very nice, though, and was impressed that I told her that my preceptor has an eye for detail and refuses adjust her high expectations of me.

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[TD=class: bogus]WHAT I LEARNED THIS WEEK: Have a plan. Stick to it, so that when things go south, you will have time to figure out what to do.

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