Organization and patient care

[LCS]

This may fall into the "this should be obvious" category but...When you're caring for a patient, how do you know what to do?

I know you start out by doing the assessment, morning (or evening) meds as scheduled or PRN, and bath...but from there on out I'm lost. Even at this point, is it okay if I do the bath right after the assessment? This seems likes an excellent opportunity for the skin assessment.

In past clinicals I've asked and have yet to receive a straight foreward answer. Initially, I think care plan...but this is the crux of the matter...where are these elusive, yet integral to the role of the nurse, documents?! How do I plan my patient cares when I don't even know where to start? How do I know who needs what and when? When is it appropriate to implement a nursing intervention (do I need approval beforehand?) Is each hospital/agency different? I desperately want to be efficient AND thorough; but I need a game plan before I can be either.

I sincerely thank any and all who can help!!!

[UM Review RN, ASN, RN]

See, you're still a student and things are different for you because no one wants to overwhelm you. This is probably why you can't get a straight answer.

But you're going to be learning these things, so I'll do my best to give you an outline. If you have questions, I'm sure there are a lot of us who are happy to answer them.

To get back to your answer: I have a tech do the bath. I use that time to read the H&P, Dr. Progress Notes, nursing notes, and look up the labs.

You can't know where to go with any patient unless you know what's been going on.

As a student, the bath part might be really important to your instructor. But as a nurse, keeping the patient alive and moving forward in a course of treatment is more important than a bath. Your tech can do those things.

You as the nurse facilitate the patient's treatment progress by following the standard of care--in other words, the care that is expected of the nurse. You might find your hospital has expectations of what the nurses should do for any patient with a certain diagnosis and has this written down somewhere as hospital policy. Find out where those are and use them.

If there is no hospital standard policy, then you get a care plan book and a diseases book that has diseases and how to treat them, and you look up each patient's diagnosis to find out as much as you can about it. (Also please remember that reading the doctor's notes is essential because if the patient is admitted with one thing and then tests prove it's wrong, the whole game plan changes.)

(I have the PDA version of this book. It also has nursing diagnoses in it for each particular disease: http://www.amazon.com/gp/product/080360811X/002-7238694-7588801?v=glance&n=283155 . You also want a Lab & Diagnostic book, so you'll know how to prep the patient and what the test results may mean.)

This way the patient is getting a nurse who KNOWS WHY the patient needs such-and-such med at such-and-such time, and who KNOWS which labs and treatments are important and when.

These are all things that you really will learn as you gain experience as a nurse.

I hope I didn't ramble too much, but your question is a pretty complex one. Perhaps others can elaborate more clearly.

Let us know how it goes! We want you to succeed!