Please help with any tips for a new grad struggling

Hey fellow new grad!

I am in your shoes right now! I've been an ortho nurse for over three months now and I'm fresh off orientation.

I'm gonna be honest. Some shifts suck. Some nurses are rude and will be rude no matter how well you do your job.

But it gets a little easier with every shift. I still get anxiety and I still have moments where I don't know what to do. Always ask.

I ask everyone from nurse friends to doctors to house supervisors until I get an answer I'm satisfied with.

Don't let it get the best of you, fellow new grad. We'll get through the daunting first year. :)

Q4 assessments on the floor? Really? Why? I'm a little confused as to why your patients are on the floor if the acuity requires that much assessment?

Also....delegate. It does not take an RN to feed a patient. Do your neuro checks and vital signs while you're in the room helping the patient. Document the neuro check quickly before you leave the room. Do your aides not chart i&o?

Q4 assessments on the floor? Really? Why? I'm a little confused as to why your patients are on the floor if the acuity requires that much assessment?

Also....delegate. It does not take an RN to feed a patient. Do your neuro checks and vital signs while you're in the room helping the patient. Document the neuro check quickly before you leave the room. Do your aides not chart i&o?

It's a step down unit and that's what the policy is. These are patients coming from ICU who are not stable enough for the floor.

I agree that I could delegate this but it just seems like we don't have enough aides to help everyone. So if I don't do it, the patients breakfast gets delayed. I do see that I could chart when I'm in there. I don't think our CNAs document I&Os for some reason. Seems to be the norm here. I just make sure I do it each time I do my VS.

It's a step down unit and that's what the policy is. These are patients coming from ICU who are not stable enough for the floor.

I agree that I could delegate this but it just seems like we don't have enough aides to help everyone. So if I don't do it, the patients breakfast gets delayed. I do see that I could chart when I'm in there. I don't think our CNAs document I&Os for some reason. Seems to be the norm here. I just make sure I do it each time I do my VS.

Gotcha.

Stuff like this gets better with time. Cluster all care. Cluster all charting as much as possible. You'll get a routine. It just takes practice.

As for the people who grill you about irrelevant things...you learn how to tune them out. 99% of the time they just want to hear their own voice. As for knowing what different procedures are, you'll pick that up over time too. It's overwhelming but you can't expect yourself to know it all. Time and exposure.

I have a few suggestions in regard to your numbered points that I hope may help:

1. Find out the procedures/surgeries that are most often performed for the patients that you see on your unit, and study them on your own time. Then study the ones your unit sees less frequently.

2. When nurses give report to you at too rapid a pace for you to write anything down, insist politely and firmly that they slow down. When nurses try to hurry your report along, try asking them why they are hurrying you. If they say you are reporting unnecessary information and/or are disorganized, take that into consideration, but if their criticism is unjustified and you are reporting information that is important and necessary to the patient's care in a reasonably organized manner, state that.

3. I suggest asking your preceptor for help with prioritizing your nursing care. I was wondering why you found it necessary to put patient bathing ahead of important patient assessments/nursing interventions which are ordered to be done at scheduled intervals, i.e, neuro checks; vital signs; medication administration; documenting I & O; and why assisting the aide to bathe a patient takes 45 minutes.

4. You can always suggest to nurses asking questions about the H&P etc. that you don't have the answers to, that they look up the information for themselves.

Hello there! I too am a fellow new grad that's been on my own on night shift telemetry for about 3 weeks after a 3 month long orientation (very fortunate if I may say). I totally know how you feel and am still feeling some of it now but maybe it'll shed some light/hope knowing that you are not alone out there and here are some things I've learned/do so far based on your numbered responses.

1) Focus on the most recent history of the patient and history that pertains to reason why the patient is there. If there is extra history, just ignore and it is not something that is needed to be passed on in shift report.

2) I felt exactly the same as you when I was giving shift report when I first started. I knew my report was crappy because of the extra questions the nurse would ask and you can tell they are getting irritated that the report is all over the place. To fix this, I learned to make a "brain" and to organize my report so it flows and I got input on this from fellow nurses and my preceptors. An example of a decent shift report can be:

- Patient info, the docs involved, chief complaint/actual diagnosis, QUICK relevant PMH

- Next would be ER info if relevant/other complaints relating to the diagnosis

- Radiology info (CXR, CT, etc)

- Next is what things have been done to the patient in the previous days or yesterday (dialysis, thoracentesis, foley catheter, RN skills, etc)

- What you did that shift and the plan of care (continue IV abx, diuresis, etc)

- Last but not least your assessment + PRN meds you gave

Problem is, we don't always have the time to structure a shift report exactly like that so at this point, it kind of turns into experience I guess? Like for me, my most recent shift was probably the busiest/worst shift I had so far as I was so backed up that by the time it was shift change, I didn't have much time to organize my notes so I basically wrote down important stuff and incorporated last shift's report and my current shift/what I did while talking to the nurse and honestly, I think it went pretty well. I was able to remember the things I did overnight and incorporate it in the report so it wasn't completely all over the place. I stayed a bit longer just to make sure I got everything done and that I didn't forget anything in the shift report.

3) It's as everyone says, time management. Fortunately I don't have to neuro checks on my floor (stroke patients are sent to the neuro telemetry floor) so on my floor have the typical Q4hr assessments. But yup, it's all time management and clustering care so you minimize the time running back and forth between the patients room, med room, and supply room. I'm bad at this too, but delegate!

Also, ASK FOR HELP! I am super bad at this. As mentioned earlier, my most recent shift was terribad simply because I got an admit at 0530 who was currently already on 1 unit of PRBC that would be ending soon but was ordered to get 3 more PRBC (I would be giving 1 unit on the rest of my shift). So on top of giving blood (which would be the 3rd time giving blood since I started), I still have to the admit stuff, med recs, orders + whatever else my other 3 patients required (fortunately it was only an accucheck haha) + charting. My coworker already knew I was gonna have a hard time because she got report for me on the admit and not only offered to help, she told me she would get the stuff ready and that she would not take no for an answer (love my coworkers/friends). Without her, I don't know if I would have made it out of that shift without screaming. What it boils down to, ask for help. Ask your charge nurse, or meal breaker or coworkers (hopefully by now you kind of know which coworkers you can ask for help). Even if it's an IV start or hanging abx or giving pain meds. If you're busy ask if someone can get it for you.

4) Kind of ties into 3. If you can start to develop good time management, you will start to miss things less. Also, keep track of what you need to do. Always look at current and new orders and your MAR (med list) every hour or even more frequently so you won't miss anything. When and if you have downtime, double check to make sure you aren't missing anything. Also, you can use that time to research on your patient.

Sorry for such a long response, but I hope my experiences/advice as a fellow new grad will help you. My nurse educator said there are 2 rules when it comes to nursing:

1) the bleeding always stops

2) the shift ALWAYS ends

So, keep your head held up high, ask for help/advice, and most importantly, make sure your patients are safe and be confident with them. Fake it till you get off shift!

You asked about the H&P, and I want to add that it is important to know the patient's medical history, not just the medical problems related to the current hospitalization, as the patient's other current/past medical problems will often affect and be affected by the most recent medical problems that the patient is currently being treated for, or the potential will exist for this happening. So, yes, reading the H&P is important. For example, a patient with an MI may have a list of other medical problems, i.e. a history of hypoglycemia; previous history of a stroke; chronic renal failure, etc. The patient could become hypoglycemic during the time they are under your care, or experience a worsening of their renal function, or experience bleeding problems related to some of the blood thinners given due to their decreased renal function, and it is the nurse's responsibility to be aware of these things, and assess the patient, monitor their labs, and intervene accordingly. The nurses you are giving report to have the responsibility to read the chart also, and while it is appropriate to expect that you will know the patient's significant medical history, it is not reasonable to expect you to be able to list in report a broken arm the patient experienced 50 years ago.