Residency Woes: A Preceptor That's a Stickler for Charting

[chemshark, BSN, CNA, LPN, LVN, RN, CRNA, NP]

Quote

"This entry is not wrong, but it's not the way I want you to chart."

Ugh, I have to schedule my lunch breaks around it. It doesn't help that I have to be supervised to give oral meds, either. It slows everything down. And after finishing my midterm eval, my preceptor told me that it's time to start moving me up to three patients. It's exhausting.

We get a lot of critical patients. But when we call a rapid response team--it's not fun. Not fun at all. Firstly, I don't get to participate in the code. Only the ICU nurses and my preceptor do. I could help out, but then it slows me down A LOT and my other patients end up being neglected. The orders pile up, somebody always wants to go to the bathroom or a PRN, I'll end up missing charting timelines, or worse--letting my infusions run dry. So I typically just ignore the RRT.

How I feel when the RRT comes in - Sometimes I get a little jealous that my other classmates have such critical patients to care for. They are able to interact with families who are having the worst day of their lives. Sometimes they even lose patients, which I know is terrible, but makes me feel like I'm not part of critical care. Most of my patients are semi-stable, so the unit makes up for it by admitting more new patients after the other. On some days my preceptor and I are giving care five to six patients simultaneously. The Corpsmen do their best, but most of them are gone this week because they are studying for tests for advancement (promotion).

One of our patients is mentally ill and he's not allowed off the floor but he's been with us for so long that we just let him walk around the unit. He can't go home because no one will take him and he has no family. So he just rambles to himself and steals other patients' food. Sometimes he'll go to my desk and rift through my bag. It's annoying. But after a while I laugh because it's just all so absurd.

At the end of the day, when the entire staff at the end of the shift are scrambling to get things done before handoff, my preceptor patiently goes over my notes with me. Though she never lets me have a mental break: "This entry is not wrong, but it's not the way I want you to chart." I feel like she is deliberately looking to criticize everything I do. But then I remember that even though my next hospital won't have the same policies and procedures, my preceptor is teaching me how to pay more attention to details. She doesn't want any patient to not get the same high quality care that she expects. Everyone gets treated the same--even if they (though mostly their family) are a pain in the butt.

When I was discharging my last patient, she watched me give instructions to some family members about new meds, appointments, and how to change a Foley bag. Then I wheeled my patient to the parking lot. When I came back, I started to apologize to my preceptor for taking a long time to teach the patient--I thought she was going to chastise me for falling behind. But then she cut me off. "Actually, I thought it was 150% fantastic that you made the family take turns showing you how to do the procedure. I could see that they became less anxious [about doing it at home]. Well done." Upon hearing this, the entire unit stopped cold and looked up. One of the RNs said, "OMG! she just gave Howie a complement."

Even the mentally-ill patient clapped and cheered.

I still have a hard time remembering all the policies & procedures, so I take notes of the skills & competency needed to work on the floor. I'm still not done, but I hope that the next person who interns after me will find it useful. I will give it to them when I'm done:

4 Hour Nursing Note

Append to NOC shift note; do not enter Noelle's name--just save yours under ancillary: some things to include. LOC; POAWAKE verbal instructions given; fall precautions; sample: pt awake and in no acute distress or pain. AxOx3 denies cp/sob/ha/n/v/d. Pt resting comfortably in bed watching tv. Pt l hand/arm +3 edema, arm/hand elevated on 2 pillows, ice pack applied. POC = am meds, possible discharge. POC discussed w/pt, pt communicated understanding. Limb alert bracelet in place. Fall precautions in place, bed alarms on. Will continue to monitor pt.

Nursing Assessment Note

Document each system. Do not use an expanded exam if it is all normal. However, make sure that your entries make sense. Choose options in the correct order. Do not guess. Do not lie. Run back into the room and ask the patient before you chart. Better yet, stay in the room to do your charting. Must be done by mid-morning to avoid the rush. Do not sign preceptor's name. She will do it. Save before exiting.

Hanging IVPB

Verify order. Notify pharmacy, then wait to be filled & delivered via tube. Otherwise, pickup. Verify right drug, dose, documentation from PIXSYS. Get solution bag (usually NS or LR) and prime. Then get piggyback bag and place ABOVE solution bag. Prime antibiotic piggyback and attach to the top port. Label ALL bags and tubing with your date/time/initials/number of bags to be infused. Clamp both and deliver to patient's room. Verify 5 rights, including allergies and that you know the medication is compliant with that solution. Flush the catheter site and ensure patency and that it's not expired. Double check the medication, patient, volume and rate again. Program the Alaris pump (both piggyback and basic infusion) and double check again. Hook up the tubing to the patient and start the infusion. Check for flow. Set an alarm to come back when it is almost time to switch/turn off/discontinue. Return w/in 5 minutes if it is a new medication for the patient or if she is sensitive (e.g. Red Man's syndrome).

Administer Blood

Do Type & Cross. Order and pickup blood at appropriate time (blood must be completely administered w/in 4 hours). Filter blood through specialized filter tubing. Setup 0.9% NS 500 mL and prime and connect to tubing. Provide and administer pre-medications if needed. Flush and hookup saline/meds. Verify blood & identification with both staff, including allergies. Start at 1/2 speed. Document everything. Vitals q15. Do not leave the room.

Admitting Patient from Tow

Look for COMPLETED NOTES: 1) 24 Hour Note (make a new one), 2) Admission History Note (new, for ICU patients only), 3) Med Requisition Note, 4) Admission Assessment, 5) ED Transfer (ED only). Ensure that transfer notes are signed by resident or attending. AN INTERN DOES NOT COUNT. Look online to see patient's location and call the department for a report and time of expected transfer.

Discharging a Patient

NOTES to be done: VS, 24 HR Nursing note (make an entry:"Assumed Care" and "Discharge Entry"); Multi-discharge summary; Clear Orders; Print 2 copies of Patient Discharge Summary (create note).

Documenting Strict I/O

Do not take patient's word. If unobserved, note NOB on the IO. Must be done q2 hours. Chart at top of the hour, do NOT start a new time column! Check that the input and output correspond and make sense every 4 hours.

Documenting Vital Signs

To be done at 0700, 1100, 1500 (give or take 30 minutes) without fail. Include pain and if they have pain CHART WHAT YOU DID to relieve it, even if patient refuses (chart that). Don't forget to include O2 delivery even if it's room air, then chart 0.00 Liters. Don't be lazy.

Documenting Treatments

Never leave an entry blank. Make sure that you chart all the education you provided. Change it up. Document at least three teachings q4 hours. Check and chart for O2 setup, dietary changes, pain and positioning.

Documenting Invasive Devices

Go to Flowsheets > Invasive Devices. Choose the correct options including date placed, how many days it has been in, what location, what type, and that the doctor is aware. Chart that you inspected it, flushed q4 hours, and that it is not infiltrated.

Clearing IV Infusions

Go to Alaris pump, press 'volume infused' and chart the number (make sure you add 'mL').

Documenting Meds

DO NOT document meds. There is no bar code scanner. Preceptor has to do it. But she can watch you give meds. Make sure that you annotate the infusion volume so that you know how much you infused.

Labeling Tubing

Ensure that you have the correct tube color, if it is a BLUE top it MUST BE FILLED to the cap. Call ahead if you are going to tube the specimen down. Notify physician if it is asked to in the order.

Labeling Multi-use Vials

Must have date, time initials. Date opened, and date to expire (should be 30 days from first opened)

Preparing a New Room

Ensure housekeeping has finished sterilizing. Determine if patient needs isolation precautions. Obtain a report. Gather urinals, blankets, and basins if needed. Gather extra equipment such as a commode or seizure pillows if indicated. Ensure that O2 setup is prepared. Urine hats for women and urinals for men.

Attaching a Tele

Call the Tele department and let them know which patient you are attaching it to. Also tell them the device number. Call if you are ever going to remove it.

Picking Up Medications

Discharge meds from the pharmacy on the 4th floor. Inpatient meds to be picked up at the pharmacy down the street.

PICC lines

Keep sterile. Use chloroform only when accessing. Make sure you have an order. All TPN lines are used for TPN only.

Code/DNR Status

Since I can't see the orders, go to Notes menu and if it says anything on the Topic area, i.e. "resuscitation plan" then it is full code and you can assume that.

Admission from ICU

Need 5 Notes: New 24 Hr, New Admission Hx Note

Admission from ED

See admission TOW requirements. There will be 4 notes instead of 5 because Admission History Note will not be needed for ED patients.

PICC line removal

Request for a physician to be bedside in case clot dislodges (if you know thrombus is present).

Glucose stick

Do not take patient's word. If unobserved, note NOB on the IO.

Unit Policy

Flush IV catheters q4 hours; Label bags,[

Chart Mistakes

MAKE SURE YOU ARE CHARTING ON THE RIGHT CHART VISIT (NOT THE PRESTAY)

Medication Timing

You can only retime medication ordered 'daily'. Scheduled medications on qnhours cannot be retimed.

Return from OR

Re-assess patient and add new entry into 24 hour nursing note; Double check orders -- medications[

Isolation Precautions

Chart on the treatment screen ('DONE'); The isolation carts are usually in the isolation rooms. Wheel one outside and place by the patient's room with a sign to indicate what type of isolation precautions there are. Acknowledge order.

Notify Physician (MEDS)

Call Corresponding Physician. Afterwards, annotate on MAR after right click.

Obtain Blood Culture

Similar setup to blood draw. One blue one red bottle.

Foley

Empty q2hours under I/Os. Don't let patient trip on it. Change after 5 days.

Charting Giving Meds

DO NOT CHART UNDER YOUR SIGN-ON.

New Admits

VITALS & EKG ASAP. Do not chart anything else until you have orders.

Drawing Blood Cultures

Obtain TWO SETS: "One boy and girl" pair. Place syringe, butterfly needles and tubing and needle transfer chamber in BIOHAZARD bags with extra bags. Start with the hand. You MUST DRAW at least 10cc--and transfer 5cc to each bottle. Repeat for the next pair. Label accordingly and tube down to the lab.

Perform a Road Test

Verify order. Notify Corpsman. Attach pulseox and vitals machine. Obtain a wheelchair if you might need one. Never leave the patient. Take to the bathroom first if needed. Document how many laps around the station the patient walked and their disposition as well as pulseox (high and low). Notify physician by phone and chart.

Tracheostomy Care

Verify standing orders for O2. Check that suction is working and there are suction supplies in the room. Observe O2 sats. Preoxygenate if suctioning or doing trach care. ONLY use specific trach gauze and mild cleaning solution. DO NOT DISLODGE SHILEY!!! If this happens, call for help immediately!

Suctioning

Pre-oxygenate. Use Yankauer unless otherwise indicated such as deep suctioning catheter. Check O2 sats and respiration rate. Stay clean/sterile.

Due to Void Policy

If patient is labeled incontinent, then she is usually due to avoid within 2 hours. If she is not able to void spontaneously and on her own at the alloted time, then do a bladder scan. If bladder volume is >500 mL then offer one final chance to use the bathroom. Stress incontinence is still incontinence. Volume voided is what's important. If it is not sufficient (the entire bladder) and there are still >200 mL in the bladder, prepare patient for straight cath or Foley re-insertion.

Weaning off O2

If plan of care is to wean off O2, then take off of breathing device and obtain O2 sats. If >93%, allow them to continue on room air. Check sats again every so often.

Fall Precautions

Must have yellow bracelet, fall severity falling star signage in front of room (bottom if bed A, top if bed B). Document on Nursing Assessment and Flowsheet > Treatments. MAKE SURE BED ALARM IS ON AND CALL BELL NEARBY.

Limb Precautions

Colored Pink and should be attached to the limb that it is protecting. Document on Flowsheet > Treatments and Nurse Narrative.

Vancomycin Infusion

Check for Red Man's syndrome. If found, stop the infusion and notify physician. ONLY RESTART IF GIVEN PHARMACY AND DOCTOR'S ORDER TO RESTART -- & usually this is at a slower speed. Suggest medication such as benadryl IV.

[grad2012RN]

Didn't read the entire article. But, from what I read you have a FABULOUS preceptor. I had to teach myself too many things. I truly think I would be a better nurse today if I had the kind of preceptor(s) you have.... one who is FULLY dedicated to make certain new nurses are CORRECTLY trained. It hurt me professionally and I'm still saddened that my preceptors used this important time to talk on their phones, have fun at the nurse's station, and answer my questions with two (2) seconds answers or demonstrations, then walk away. You mention this to management and nothing changes. You continue on or risk being released from that entry-level job, because you want so desperately to practice nursing.

Be happy that he or she is a great nurse and want the same for you!

[Neats, BSN]

I agree you have a fantastic Preceptor. Be a sponge and soak this all up because when you are on your own you will be grateful to that nurse, heck I am grateful to that nurse and I do not even know who they are. I would gladly work along side some one like this.

Be grateful. I am reminded of this new nurse I was training (I am not saying you are like this at all so please do not get offended).

New nurse ADN had to give two TB injections then wait 2 days to have the patients come back, these patients were in the prison.

New nurse was not available on the 2nd day, the patients came up to me showing me their arm where clearly the skin was necrotic. In short the nurse gave tetnus instead of TB. To correct the new nurse I was invested in their success I took them away from direct patient care for one week to log in and place supplies where they belonged, to get to know what the supplies looked like (they included DME and pharmacy medication). After 2 days the new nurse gave their resignation stating I want to work direct patient care. I told them I want you to work direct patient care safely...I am thinking your preceptor who is investing in you wants the same thing.