Research patient or see patient first?

[RNingBSNing]

Hello,

A novice RN here asking mostly for professional opinions.

I've noticed that older and more experienced nurses will get report in the morning, take down notes from the night shift on their patients and point any questions directly to the night shift nurse. Then, without looking in the EMR, they automatically start their day by seeing their patients, doing their assessment and getting vitals.

Newer and younger nurses I've noticed tend to come in earlier, spend endless time in the EMR looking things up and then get report and either spend more time in EMR or see their patients. I can't really discern if either system works better or not.

The newer nurses I've talked to feel like they're catching things they might otherwise miss (low blood glucose on AM labs, Med not given, etc.) but the older nurses seem to think that if any of that really mattered then they would see it on assessment. For instance, a patients blood glucose or potassium could be really low, but does seeing that on a computer screen do you any more good then actually having already assessed the patient?

[smf0903]

This may differ based on the shift too (I work 7p-7a) but I always pop in and introduce myself before looking at anything. A quick visual gives you info like how they appear (writhing in pain? Are the drowsy? Are they diaphoretic?) Speaking to them "Hi my name is smf0903 and I'll be your nurse tonight. How are you feeling?"

I don't do a full assessment until I've skimmed the chart. Usually by then there are meds to pass and I like to know things before passing meds (labs, vitals, etc). Then I do my head-to-toe assessment.

I'm not sure there's a wrong or right way, you find what works for you :)

[KatieMI, BSN, MSN, RN]

You are there to treat patient, not chart or numbers. Therefore, whatever is written there is important only in conjunction with patient's condition.

Two guys, same age, med/surg, both have Hb 7.0. at 6 AM. One is ESRD on dialysis, feels fine, A,Ox3. Another one is on watch for upper hip/groin contusion and DT, 8/10 back pain, dizzy, confused x1- 2, sweats all over, asks for water all the time. Not knowing anything else, even without vitals, even not knowing anything about "retroperitoneal bleed" and acute ETOH cardiomyopathy, a nurse should direct her attention to the guy #2 because something obviously going on wrong with him. It would be nice, of course, to know if the guy #1 has Aranesp on board and his protein was upgraded by dietary, but that can wait. Guy #2 gets tele, VSsq1, doc gets called for fluids, U/S, etc., . and sorry, no water till we know what's going on with you, buddy.

Perusing a chart of the guy#2 will get no useful info except baselines, which would be nice to know but not the first priority (and, honestly, departing shift RN should know them).

It is all named "clinical thinking" and comes with time an experience to almost everybody dealing with sick people, providing there are opportunities to access patients several times a day and analyze results.

[Cowboyardee]

The general trend in nursing is toward bedside shift reports, so many nurses, experienced or not, are tending to see their patients before becoming fully acquainted with their charts. That whole subject is kind of a different can of worms though.

In general, I get report while simultaneously glimpsing at overnight labs and usually the most recent physician's note, radiography results, and pending tests. Only adds a few seconds to the nursing report time. At this point I know enough that I am not often caught off-guard by a question from my patient or their family. I then pop into my patient's room to do a quick pre-assessment: vitals, drips, mental status if awake, ventilator numbers, and anything that might set off my spidey sense for something being wrong. Takes maybe 5 minutes.

I often will then call for additional orders that I might need based on what I'm seeing so far - anything I want addressed before rounds or the morning medication pass. I'm generally pulling meds before I've been at work for an hour, and I do full assessments while administering medications and treatments. I can be pretty flexible if there's some big issue that needs to be addressed early.

I try to take the time to more thoroughly review the chart before morning rounds with the physician, making note of any questions I have or anything that needs to be tweaked. I don't like to be caught off-guard in rounds.

This works pretty well in critical care. You might need a different kind of pacing depending on what kind of unit you work on. I'm probably what you'd consider an experienced nurse, for whatever that's worth.

[Sour Lemon]

That depends, almost entirely, on who I'm getting report from.

[mrsboots87]

That depends, almost entirely, on who I'm getting report from.

THIS!!!

[Purple_roses]

I'm new too, so also trying to figure out how stuff works. We do bedside shift report, so that gives me the chance to do a superficial assessment on the pt (A/O, any signs of distress, pain, quick peek at surgical incisions, etc.). Sometimes I come in a little early to look through the charts and think through what I'll need to do for each patient on that shift. But whether I come in a few minutes early or not, I've been getting beside report, looking up meds/labs/providers numbers in the chart, and then do my assessments. I feel like I save time by doing this--instead of doing my assessment, figuring out that the patient has a med due that moment, running back to get the med and then coming back, I can just bring everything in the room. However, I do not follow this game plan if my patient had a rough night or is critical--I make them the first patient I see and I see them right away just to make sure they're doing ok.

Sometimes I still feel like I miss things in the charts, and I'm honestly getting pretty sick of coming in early without getting paid. So eventually I am going to try to figure out how to glean all the important stuff from shift report to save the charts for a bit later.

[RotorRunner]

It's always been my policy to lay my eyes on the patient first thing.

I don't say that you shouldn't trust the outgoing shift report. I say, TRUST AND VERIFY. And there's nothing in a bunch of labs or H&Ps that you can't get at the bedside with a good physical assessment.

[MurseJJ]

I'm new as well (7 months in). Some of my colleagues would come in pretty early to look everything over in the computer. I stopped doing that quickly (often the assignment wasn't ready anyway). Also, some take report without looking at the computer. We do bedside report where both RNs go into the room and introduce the oncoming shift, and you should be looking at any relevant assessment items, IV drip rates, vent settings, drains, monitors, etc.

What works for me is that while I'm getting report (we use an SBAR sheet), I look through all the orders, vitals, and labs. I try to be systematic about it, so, for example, when we get to discussing vitals, I open the VS flowsheet and look at how the most recent set, as well as how they trend. I'll also make sure all labs were taken (and if they weren't you should ask why), as well as look at the MAR to ensure all meds were given (again, ask why if something wasn't). After that we go see the patients, I make sure there are no immediate concerns/needs, then I go back to the computer, look over the orders again, do my 12 hour check, write down the times for meds/treatments/etc, then I can go and start my assessments, etc.

Later in my shift I'll try to look at the most recent note from the team (and any other relevant note) so I can get a more complete understanding of what's going on, as well as more of the plan.

In my opinion, the best way is to combine the two styles you see. Yes, you should be seeing why something wasn't done at the beginning of the shift, but you shouldn't have to come in very early to do that. You can see that during report on the computer (and think about it, getting report involves obtaining the information you need to safely take over caring for the patient. That involves knowing vital signs trending and relevant laboratory data). Yes, the clinical presentation of the patient is what you treat, and is important, however you also need to know the actual values of the abnormal vital signs or labs.

Hope that helps

[Been there,done that, ASN, RN]

I don't see how a nurse can be nose deep in a chart without eye-balling their patient.

As soon as I got report, the patient was MY responsibility. I always started my shift with a quick visual assessment, made sure I wasn't left bad or there was not a change in condition.

Plenty of time to go through the chart after you know the patient is okay.

[RNperdiem, RN]

When my kids were little and learning to read, I learned the term "picture walking". This is where you do a quick skim of a book to get a basic idea without spending a lot of time on any book.

After report I do a quick "picture walk" of the chart. I skim over the vital signs, see what meds there are on the MAR, check the labs and check the EKG, and then I am ready to see the patient.

[Nurse SMS, MSN, RN]

There is no one-size-fits-all answer here. Depends on the report. The patient. Whether I have had them before. What kinds of issues they are having. Prioritization is a big part of what we do.