qaz99

I used to struggle too until I realised the easiest way is make sure you have the same structure for each note. Body systems/head to toe is good to use I think. You mention all the systems but you don't need to go into detail about all of them unless something happens or is important for oncoming staff to know. My notes follow this structure of head to toe: Neuro: are they alert and orientated? Or are they confused? Head injury - include MSQ. Sedation levels.What's their pain like/what did you do for it? cardiovascular: we're they hypo/hypertensive? Tachy? Brady? Why and what did you do for it. I also include how many cannulas they have and what fluids are running. Respiratory: what are their sats, WOB, are they on 02. Gastro: tolerating diet? Nausea? If so what did you do for it. BSL issues. Did they open their bowels. Genit: do they have an IDC in? Draining okay? Or are they passing in bottle/pan. Was an MSU collected. Skin integ: skin intact or is there a skin tear - if so what did you do for it/apply dx. 2/24 turns/reposition etc. mobility: are they indep or do they use 4ww or are they rest in bed. How many assistance to get them up. Social: did family visit, any issues or queries from pt. Not every patient needs a long winded explanation of every system. I don't go into all the vital signs of cardio and resp unless they were having issues. So I might not mention their sats or BP if it's all normal. Instead I'll just say 'vital signs within acceptable parameters'. Example below (as you see, it's a condensed version of above and I only really mention what's relevant to the pt, don't need to explain everything). Below is from a made up pt too, btw. Also, not from America so my terms used might be different. Pt alert and orientated. Moderate c/o pain to R) hip, PRN analgesia given as charted with good effect. Pt hypertensive this shift, BP 178/94, STAT dose of Amlodipine given with good effect. BP 142/70 ATOR. All other vital signs within acceptable parameters. PIVC x 1 L) hand patent and intact. IVABs given as charted, IVF running at 82mls/hr. Pt vomited x 1 after eating lunch, 4mg ondansetron given with good effect. Pt currently tolerating small amounts of fluid. IDC insitu, draining well. BNO. Skin intact, assisting with 2/24 turns for PAC (pressure area care). Pt SOOB for lunch with stand transfer x2 assist. Teds/SCDs insitu. Nil other concerns voiced. Thats how I do it anyway. Hope it helps.

Start a petition for zero tolerance, get enough signatures for the government to step in? This is pretty much what has happened in Australia. Paramedics especially were getting assaulted too often. They started a zero tolerance campaign, got the government behind it and now my state has added a maximum sentence of 14 years for abuse against health care workers. There are now various adverts aired on TV and posters around the hospital bringing awareness to the fact it's not acceptable and there will be consequences. Adverts currently on TV: Management at my work also encourage good documentation and use of incident reports when a form of assault occurs at work so they can actually do something about it.

Chill, guys. She resigned the proper way via letter and did the cake after for a bit of fun.

I guess it comes down to different practices and routines. We have only just rolled out electronic documentation but meds are still kept on shelves/or locked away (CDs). Which is why we also have CD key delagatees. These are people (usual team leader and someone else) who are given the extra task of being a witness and carrying the keys for the CD cupboard. So really, I can't actually even open the CD cupboard without having another person there because that other person will have the key. When it's 8am and the whole ward requires CDs, I only have to wait a maximum of 5 minutes. Just today, two nurses were doing a CD check in the med room, someone from another floor came and tried asking questions while they were counting. TL saw this and reminded other staff member to wait until after CD was given before discussing something else as mistakes can happen if two people arent watching what's going on. Maybe because I work in Ortho, we're a bit pedantic about pain meds but throughout numerous hospitals I've had pracs on, it's been much the same. Maybe storing CDs in locked cupboards and delegating a team leader with reduced patient allocation the responsibility of opening CD cupboard and witnessing would help ensure policy is met/reduce mistakes instead of the Pyxis. At the end of the day, I know there's a lot of rubbish policies that are pointless or not real word nursing but CD administration is pretty important. And if a time comes where you sign someone off when you didn't actually witness them *properly* because you 'trusted them' and now you're in court, like there's no one really to blame except yourselves.

But this is exactly what happens in Australia. It's not hard to find a nurse to follow you for 10 seconds. i can't fathom how you guys are allowed to pocket remainder of narcotics until whenever you feel like getting a witness. Its asking for trouble and accusations.

That's odd. In Aus, you *have* to have 2 nurses present the whole way through a controlled drug administration. From the med room where you get the drug out, you dispose the remainder there and 2 nurses sign for the disposal in the controlled drugs book, then you walk together to the bedside, check ID and both nurses must see the patient swallow the med/nurse administer it. Seems to work well. Its not common for nurses to be pulled up for drug diversions here because the system works. If I were to administer a controlled drug without another nurse present, for example, then there wouldn't be a second signature in the book which would be an immediate red flag within minutes to whoever next signed in the book.

Satire, not for everyone �� hint: OP is saying, "we all have time to pee if you get off your phone and quit moaning"

Does anyone else 'prefer' male patients to female patients? When I get assigned a room of elderly female patients, I know I'm in for a heavy shift. Compared to the males, they moan/are pedantic over little things, take twice as long to do everything, seem to be more susceptible to delirium/suffer the symptoms of dementia more than males (obviously not their fault). But can also be cranky and refuse care. Whereas with elderly males, in my experience, they're easy going, allow you to do observations without a fuss etc, still have some sense of humour despite their alzheimers/dementia diagnosis, talk to me in a respectful way. And I can relate to them easier as at 90yrs old, they can still hold an interesting conversation, and even throw in funny one liners. But the 65yr old female will either be extremely difficult to interact with or nitpick. Hope I don't sound bitter or anything. I'm not saying I dislike or hate caring for these patients, obviously they're in pain or really ill which affects how they interact. Just find it interesting how easy going elderly male patients can be compared to the females.

I think it's the same in Germany. Nursing isn't regulated and you don't go to Uni to become one. My ex German bf held little respect for nurses, funny how he understands nothing about what we do as nurses yet thinks he can make bold statements about how 'easy' our job is and how it's pretty much the doctor he trusts. Researched German nurses a bit on the Internet and yeah, seems to be a low profession over there.

The Australian system is more similar to UK than America. Don't understand a lot of things people from the U.S talk about on here lol. In Australia, it is a 3 year bachelor degree to become an RN. During these 3 years, you have to do minimum of 800 hours of placement to meet registration requirements. The unis usually allow you to gain 850 hours (unpaid though). In UK it's double this! This leaves Aussie grads feeling really unprepared in their first job. You our can also become an Enrolled Nurse or EEN if you go to TAFE (vocational college). This takes approx 18 months I think. They work under the RN and can't give IV meds unless they are endorsed to do so (although some hospitals still won't allow them due to their policy). After becoming qualified as an RN, there's limited positions available for a graduate nurse if you don't have experience. So we have Graduate Programs, where you are employed as a graduate RN and work (paid) but you get additional support, education and you are transitioned in (although there's limited positions compared to all the grads every year, so it's competition to get one and over half of graduates don't end up getting one!). After a year experience, it's easier to move onto other jobs. Cannulation and blood collecting are extra competencies that need a certificate before you are able to do them. Patient ratio is usually 1:4 on mornings and 1:6/7 on afternoons. New laws are just about to be implemented though to ensure all hospitals have a 1:4 ratio (excluding ICU etc). There are no nurse anaesthetists here either, wish there was though cause their wage looks pretty good in the U.S.! Only doctors here. We do have nurse practitioners though. We have Assistants in Nursing (AINs) here, which is your HCA/CNA. There's usually 2 on each ward and casuals who float around. They make beds, ADLs, and empty IDCs. Their scope is limited. We we also get paid a lot higher than UK nurses :) So as much as I wish I could have trained in the UK (I'm English), I'm happy to be working in Aus.

I'm just about to start my first job in a busy ortho/trauma ward, beyond nervous! Thanks for the info/words of advice on this thread :)

I personally don't see an issue with this phrase. If a doctor is doing rounds and suddenly the patient asks for a bedpan or something time consuming, no 1) the doctor is doing rounds, they're busy as well. 2) a lot of residents don't have a clue on how to toilet a patient or other nursing tasks that seem easy. 3) have noticed doctors are a bit awkward when communicating with patients outside of discussing medical info, but nurses aren't, therefore we're the better person to handle these queries/tasks. Also, at the end of the day, you the nurse, take full responsibility of care for that patient. What if the doctor did delegate to the CNA instead of you, and for some reason that CNA didn't do it, you would have no idea. If someone says I'll get your nurse, they know that you are the one responsible for the care and if you want to delegate the task, then fine, but still, you should be the one to direct queries to. I think some nurses become a little sensitive when it appears they are 'taking orders from doctors'. Or I get the impression some nurses even think bed pans etc are beneath them and get annoyed when someone higher up delegates the task to them, and then they always delegate to the CNA. With patients, all they know is that they have 1 nurse caring for them for that day. They know a CNA helps out, but they also know that that CNA isn't just 'their' CNA (ie, the CNAdoesn't have allocated patients, but the nurse does) and they aren't the ones who will be always answering call bells (the nurse will mostly). There's also too many allied health professionals that we work with, in which patients may not even realise. And doctors, they don't really communicate with physio or the dietitian, but we the nurse do. So if a patient asks them something to do with their mobility, which is obviously a question for the physiotherapist, the resident probably has no idea who this person's PT is, how to contact them etc. So, ask the nurse/the person who bloody does know. And then guess what, we'll be the one's saying 'i'll let physio know/i'll pass it on to the dietitian". Unfortunately, we are the middle man for a lot of things but it's kind of how it works.

Wow, nursing school in the US is weirdly strict. Come study in Australia, flip flops and shorts galore at uni. Don't understand why a college/uni needs to enforce a dress code. It's college at the end of the day... Clinicals, yes, by all means enforce a professional look.

Forget about learning each and every drug as an individual drug, you'll get nowhere. Instead, understand the different classes of drugs, as majority of the time, most drugs in the same class will have similar mechanism of action/side effects/considerations (with some exceptions, of course). If you're working in a medical ward, you're likely to see a lot of the 'ABCD' drugs, which are: ACE inhibitors Beta Blockers Calcium-Channel Blockers Diuretics And then, as someone else said, other classes, such as: Opioids NSAIDs Antibiotics Antidepressants etc etc Learn the mechanism of action of each class of drugs, and look up which drugs fall into each class. Doing it this way will definitely help in clinicals.

I' would have thought forging the nurse's signature would be risky. Imagine if a case went to court and they said to the nurse, "is this your signature on this document?", she can't lie, and her saying no would probably mean anything charted would be admissible.