Good question. It is tough to get a routine down and just know that. We also use powerchart at my hospital (aka Cerner). First thing is first, add your patients to your list so they show up on the care compass. The care compass shows you upcoming tasks that need to be completed. This is useful but this isn't all you should look at. You can also see most recent orders/lab results here in Care Compass as "Nurse Review" it there. This is awesome because sometimes patients have been here for a week or more and it can be hard to filter through old/new orders.
Get your SBARs. Along with the SBAR, a lot of us night shifters use a separate sheet that we can quickly add Room #, Med Times (including if they need insulin, BP & HR to be closely reviewed for BP meds, etc), Procedures to plan for, K/Mag Sliding scale (Something we do at my hospital) and also charting check-offs. I've included a copy of my "cheat sheet" and I recommend if you want to use it to make your own or customize it! 🙂
Many other nurses simply fold their SBAR and on the back they write these things. So, it's complete preference.
Labs are important and procedures too but what is your patient here for? What should we focus on? These are what you should write down on your SBAR. For example, if your patient is here for CHF: What was there BNP on admission? Strict I&O, Wts... Are they on IV Lasix or PO? What did their CXR reveal on admission vs now? If the patient is here for CKD or AKI: What is there BUN or Creat? Is it coming down? Are they getting fluids or are they a dialysis patient? You may not see these patients because they are usually on tele! But as you move along, you will learn what to look for. In the meantime, ask your preceptor/instructor what THEY would look for?
By having a good picture you can kind of establish a POC (Plan of Care) for your day. It's a lot as we are essentially a coordinator for all of a single patient's care. What's the plan for discharge? That's also another thing to write down and have an idea of.
Usually, at night, I come in and review charts as much as I can so I have a good idea of what's going on with my patient and I develop a plan on my cheat sheet of what I need to do during the night. But, at any time... that can change. You may have to call rapid on a patient. Your patient may need an additional dressing change. There is so much you simply cannot plan for. So, do the best you can with knowing when meds are due (unless orders change), procedures, labs that we are monitoring closely, is there a change in labs, look for new issues with your patient.
After I develop a plan, I see the patient that needs me first, (High BP, pain, etc.) This is where prioritization comes into play! And you will learn this as you go. If I can assess during my medication pass, I do. If not, I come back. We have hourly rounding at our hospital, every 2 after 10 so I keep up with when I was last in a room to make sure I am checking on them frequently. For my sicker patients, I am rounding more frequently.
Just breathe. You are going to do fine. It takes time and some working out kinks to get a routine down. You cannot always fix or address everything and that's ok. Just keep your patients safe, provide the best care you can, and ALWAYS ask if you are not sure about something.
Sorry long-winded. 😄 Have a good one!
Cheat Sheet 1.docx
