RN_atlast

I work at a smaller community hospital that is rich in acuity, but lacking in resources. That being said we have a very high turnover, and the nurse:patient ratio is usually suffering because of lack of staff. This in turns leads to us being very busy, and I find I am staying 30 minutes late nearly every shift to "cover myself" and make sure I have charted thoroughly. I work FT in ICU, and pick up casually in ER. We have some good providers, and many others that are less inspiring, to say the least. I worry heavily about finding myself in a lawsuit (not due to my actions, but as someone who has been part of the patient's care) for an assortment of reasons. I am not saying that patients are being intentionally mistreated or anything like that, but it seems we have some long delays in care sometimes due to certain systemic issues, and we don't have the proper systems in place to rectify this. The high turnover has led to the remaining staff being allowed to essentially do as much or little as they want, so long as they do what is audited (restraints, titration, etc). I have a commitment to this community and these patients, and would like to work here longer as I am getting great experience, and can see daily how my interventions and advocacy affect patient care positively. All of this being said, how do I document to cover myself? What are things nurses are being pulled into court about? What are obvious things nurses should be documenting that they may not be? I try to be as specific and detailed as possible (ex: 0900-informed of troponin of 10. 0901- author informed Dr. ______ of troponin 10.) but still am fearful, and want to minimize my risk of ever being pulled into court and not having documented properly/thoroughly. I am looking for nurses with experience with any of the above, legal experts in the nursing field, or anyone else who would be so kind to point me in the right direction.

The patient is already on levophed, unless they’re maxed on levo and it’s time to get another pressor on board which is a different issue in itself, why would the mag be questioned? mg and K are electrolytes you look out for especially in regards to ectopy.

Work together with them. Show them you are not above doing something, that goes a long way. As a new grad you are pressed for time, making it hard to help out.

The first 2 months on my own were awful. Everything was so new. I worked nights on a busy tele/CV Stepdown, and we were always slammed with admissions. Admission charting would take me an hour. I didn’t really even understand the process of admitting a patient. Then after 2 months I sort of realized okay get report from ED, get the patient take VS and assess, call provider let them know pt is here and report abnormal assessment findings/pt complaints. Then get the orders and I’m set. It’s different for you in your setting of course. But basically, once you do something a few times for a specific diagnosis, it will become automatic. I almost think it’s harder for you in psych because there is way less objective data than the areas I’ve worked. Not comes with time. I’m a year in and still sometimes see new things that throw me off.

Now you will always check your PRN orders for your patients. Try to make it a habit to do this as early on in your shift as possible. If time-willing, I check my patient’s labs, H&P, consult notes, and imaging as early as possible. I also write down what time which meds are due, and when I do this I look at what PRNs I have to work with if A, B, or C happens. People put a lot of pressure on report. Basically in report I want to know what I can’t find in the chart, any abnormalities, any changes in the plan of care, difficult social/family dynamics so I can proceed with sensitivity. The rest you can get from the chart. If I’m waiting for report, I’m skimming the chart. Re the BP, you recognized it was slightly above the patient’s baseline and per orders did not warrant a call to the proper provider. Following that, in the future as your thinking skills develop your mind will wonder “what PRNs are there?” If any. Before I call a provider about something I usually check to see if it’s a new finding, if it’s been addressed in their notes, if there are interventions I can do already for it, etc. I’m only a year into nursing but I love to learn, am constantly studying and researching things, accept all teaching from my seasoned colleagues, and am happy to say after a year I’ve grown immensely. Can only hope I continue to do so!

I’m in Chicago too. If you’re trying for level one trauma centers and trying at the nicer hospitals (Northwestern, Rush, any union hospital here) you will have a harder time. I got into ICU with 7-8 months cardiac/neuro tele experience, but my hospital is a little smaller and not a trauma center. Needless to say it’s provided me amazing experience with amazing coworkers and I’m learning so much.

At my first RN job, if you picked up OT before your last shift of the week they would find a way to cancel you/ put you on call for your last shift so you didn’t end up with OT. It got to a point I stopped picking up shifts because it would make my schedule so unpredictable. And I’m a person who loves OT. As a previous poster said, talk to HR. At the very least ask them if there is a unit you can transfer to where you can actually work your 36 (or whatever is FT for your facility) hours per week.

If I'm assigned to that patient, I am that patient's nurse. The charge is charged with running the unit, staffing, assignments, etc and on some units they have their own patients. I have one charge who is amazing, always helpful with advice etc, and if she senses I disagree she will say "If you feel unsure about it, call the provider." But in a nice way meaning she gives advice on what she would do, but still respects that I am a nurse and the one ultimately responsible for the patient. As a courtesy to the provider and fellow coworkers, my coworkers and I usually ask each other if anyone else needs to talk to _______, so we don't have to make a million separate phone calls to the same provider.

Not unclamping the secondary is a different “mistake” than say accidentally bolusing a K rider or something. But it’s a good time to learn to take your time with medications. When I’m pulling meds or giving the patient meds if the patient is distracting me I say something like “that’s a great question, let me just finish preparing these medications and then we will talk about it.” It comes with time. I’m still a relatively newer nurse, but that’s what I’ve picked up along the way this far. Once a medication is given, that bell cannot be unrung, so just take your time with medications.

During nurse-nurse report I don’t think families should be present the entire time. There are labs, imaging, etc results which may not have been discussed with the patient/family by the proper provider yet. There are things nurses will say that wouldn’t concern another nurse, but may concern a family member such as abnormal labs etc. Sometimes I prefer to do bedside report, I can show the oncoming nurse wounds, swelling, any abnormalities etc. The family can be there for the introduction “I’m leaving, ________ will be his/her nurse now.” Also we may need to undress the patient a little to show something, and the family doesn’t need to be there for that. If the patient was alert I highly doubt they’d want their third-cousin’s boyfriend’s daughter seeing their genitals. It’s so important to keep families updated but that is a nurse-patient/family conversation, not something that needs to be done in the middle of report. The family can ask questions all day and night, I feel as healthcare professionals acting in the best interest of the patient we can limit the few minutes we get for report to ourselves. We can then use said info to educate and update family on what’s going on now, and what may be going on in the future.

If you feel like you want to try med-surg, do it. It’s a tough specialty and you get great at time management and prioritizing. You learn what tasks and patients are a time trap and how to deal with that. There are pros and cons to each specialty. I worked on a telemetry/ CV Step-Down for 8 months before I went to ICU. Telemetry ran me ragged. No matter how fast I worked I just could not provide the type of care I wanted to to my patients. I learned a million things there but I’ve always wanted to be in ICU and once I got to ICU I just felt like that’s where I loved to be and the type of care I wanted to provide. Whether it be titrating pressors on a crashing patient, or being able to take 20 minutes to give my patient some “spa time” and bathe them and do oral care well, I am happy in ICU. All that being said, if you want to learn skills go to med-surg. You may or may not like it and may or may not return to psych and/or rehab. You won’t know until you try!

No you’re not in the wrong. I’m a male so I won’t personally ever breastfeed but my coworkers who do I always want them to have time and a place to do so. When one of my coworkers needs to pump I’ll watch her patients and she goes (I’m not sure where the pumping room is) and we watch her patients until she comes back. Either way, I’m not sure why that nurse is making a big deal of it. Sure maybe since she’s been gone for a year it surprised her because she hasn’t seen someone pump there (she has been gone for a year). But I don’t think she has the right to tell you not to do that. It’s an enclosed space away from patient care for you to do what your body does. Maybe she’s someone who throughout life was only told and presented with breasts as sexual objects.

Location, location, location. The hospitals with nice shiny facilities that everyone wants to work at will probably be extremely saturated with applicants, especially to their critical care departments as med/surg and telemetry have a way of running nurses ragged. I was working tele/CV step-down in a decently sized hospital, in a system that owns multiple hospitals. I wanted ICU experience, and though I knew many people in ICU there, I opted to look elsewhere. I was there long enough to transfer to a different department, but I felt like it was a better move for me to go elsewhere. There was a strong system of favoritism there. I applied to a hospital a little closer to my place, a much smaller hospital with less resources. Largely underserved patient population. In the interview I highlighted on the step-down aspect of my job and how that experience could translate to ICU, and acknowledging my willingness to learn. I got the job and am currently finishing orientation. I love ICU, community hospitals and love nursing in underserved areas, so it works perfectly for me. Try smaller hospitals.

If not normal, similar to my experiences. When I became an RN I started on a tele/CV step-down/neuro (stroke) unit. My orientation was with one preceptor (and she was amazing, always gave me good feedback on what I did good and what I needed to improve on). I was frequently tossed between unit orientation and classes so my actual amount of weeks on the unit was limited. Then I went to nights and had a preceptor who quit, then was tossed to all different ones. Fast forward to now, I’m in my last week of orientation in ICU at a different hospital. 6 weeks of orientation total (the first week all classes) then 2 weeks of day shift where I had 4 different preceptors, and then nights. My night preceptor is a seasoned nurse but is not good at teaching/explaining what is in her head. All the other preceptors were taken. As mentioned above, it’s about surviving orientation.

1:10 sounds insane. I work nights currently, so our ratios can get high with admissions but I haven't had a higher ratio than 1:7 thus far, knock on wood. If it were me personally, I would be looking for something else. I am a newer nurse as well, so my time management is not where I want it to be yet, but I could never handle 10 acute patients at once. The nights where I end up with 1:7 I still feel like I'm drowning. Tbh 1:10 would make me sad. Who would want their family member in a place where the nurse has 10 patients? I know it is out of your control. But you do have control over applying elsewhere.