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Time Management

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Last night was a *** show and I'm looking for pointers. New grad; licensed for 9 months and 3 months into first real hospital job (step down ICU). I'm also 60 years old (and I wonder if that has anything to do with it).

Our unit does V/S q.4, focused q.4, HTT at start of shift (12 hours). NAs do not do any VS other than 2000.

I had one patient who had intractable pain - narcs every hour, allergic to everything so had to manage her hives/itching reaction to the narcs with benadryl and other options. she had 3 drains (duodenal, new nonfunctioning jtube, something else and foley). POD2. PSH of several spinal surgeries and her body looked like some congenital stuff (never got a chance to check her history so honestly no clue). she had TPN, lipids, 3 different antibiotics running into a 3-lumen PICC that, by the end of the shift, had only 2 working lumens. thankfully did not have to reposition her. She had an NG and was unable to swallow (not sure of the HX there) so for PO meds I would put them through the NG and turn off suction for an hour and hope they were absorbed.  she had BG checks q.4 in addition to pretty much hourly meds/pain meds. Contact precautions and NAs never entered the room except for 2000 V/S.

patient 2 had only an ileostomy with crappy lungs. day before I had asked day shift to request CXR and RT/Pulm consult because her lungs sounded super coarse, she had a green sputum and productive cough. intractable pain and meds q.2 hours (oxy and dilaudid) in addition to her other meds. TPN with 3 rate changes during the night. PICC line with 2 good lumens. I think she had abx - don't remember. BG checks q.4 hours. NA did one of the checks.

patient 3: New admit from ER for CHF exacerbation, only had her for 8 hours of the shift. non-english speaking but had daughter to translate. She was my easiest once I spent about an hour doing the admit, setup, V/S (only twice as she was there only 8 hours), but then her BP started dumping (high 80s/40s) and I had to spend a good 30-60 minutes focused on that. 

patient 4: POD2 with wound VAC to RLE, 3 new surgical sites, q.2 hour pulse checks, abx, pain well controlled, little forgetful and confused but stable. this was my 2nd day with him and I had asked day shift the day before for lasix because his LEs were so tight, peeling and discolored I was worried for compartment syndrome (not seriously but dayum they looked awful). he was on heparin and bridging to coumadin so I was chasing his labs and titrating his heparin also. by end of shift we were down to +3 pitting edema (huge improvement from rock hard skin) on surgery leg and +2 in nonsurgical. during the q.2 hour pulse checks (I missed one of them during the night) I had to reposition him and get the surgical leg elevated.

patient 5: bariatric POD1 with N/V unable to hold down water, pain, EtOH and drug abuse HX (I found from day shift during report), but really a very stable patient. I was in there more than q.4 hours as I was staggering her meds so she could try to keep some of them down.

So, hour one (20-21) I did HTT on 3 patients and got meds up to 2100 passed as I suspected I was going to get another patient and I wanted to be ready if/when that happened. Found out about 15 minutes before tranfer I was getting the ED xfer so I was glad I had planned for another patient.

Hour 21-22 passing meds, addressing pain on pax 1 and 2, charting exceptions to HTT, adjusting TPN and replacing all tubing (expired). chlorhexidine baths on the PICC lines. Chart 2 HTTs fully.  Check everyone's labs and make sure nothing was crazy. Give insulin like candy.

hour 22-23 pretty much dedicated to new admit.

hour 23 I got 5th patient. HTT on them and keep running all the meds

hours 24-8 I'm bouncing from patient to patient. We had 2 rapids on the unit and everyone was pretty busy. Shift ended at 0730 but day shift as a whole said it seemed like many from night shift were trashed at report. I didn't start charting until 0830 as I was still responding to the uncontrolled pain patients and making TPN changes and trying to give report (we do bedside). There were 6 of us charting from 8-9 and 2 of us from 8-10. 

So, new grad, I know I'm lousy with time management but I do try to cluster stuff and anticipate *** coming up (I will dump heparin and maintenance fluids in the rooms (after say 0100 or so) so if the alarm goes off and an RN sees it they might hang the new fluid. I keep my tubing labeled and know when it needs to be changed (all TPN, lipids and abx tubing was changed so I make sure I have that *** before I leave the med room). We ran out of 10mL flushes about 5 am so I was chasing my *** on that for the PICC line patients. 

So, pointers on how I could have structured the night better?

Been there,done that, ASN, RN

Has 33 years experience.

No nurse can handle that nightmare.  I find it hard to believe. Slide into home care until you can  retire at 62.

 

Hannahbanana, BSN, MSN

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB. Has 51 years experience.

This is an absolutely insane assignment for anyone. Don’t you dare let yourself- or anybody else- blame you for not being able to keep up. At my stellar best when I was a lot younger and prettier I couldn’t have done it either. This is a fine exemplar of inadequate staffing and  
I wholeheartedly agree, get out before it kills you

5 patients on a progressive unit?  Why are your techs only doing vital signs at 2000?  Why are they not doing your blood sugars?  There’s a lot in there a tech can do.  Delegate to them what they can do.  If you don’t tell them what you need, they can’t do it.  They could also be finding your flushes for you.  
 

Does your unit not get cath flo ordered for clogged picc lines?  You guys just let non working lumens stay not working?

It sounds like you had a busy night.  I don’t know that there was a ton you could do differently.  But I would also be pulling a tech in with me and having them do all the things that are within their scope.  

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

As others have mentioned, that was a crazy assignment. Give yourself a pat on the back for getting through that! It's ridiculous what's considered appropriate patient ratios these days given the acuity that we're seeing in non critical care settings. It does sound crazy that your techs don't have any more responsibility. Good luck with your unit!

I gave NAs assignments at 2000 and I have no idea where they went. I wonder if they were as overwhelmed as we were. I tried at 0700 but the day NA said the night one should have done what I asked him to do and by that time I was so over everything I just did it myself. 

EXCELLENT idea about asking an NA to source flushes! The NA assignments change 3 times during my shift and I have a really hard time figuring out who is my NA so I'm going to make that a priority going forward. Also I could have Vocera'd the charge.

we're supposed to place Vascular access consults daily for the PICC patients and they order the tPa but neither patient had that ordered so I couldn't. I did place consults for both of them and let day charge know though.

Techs do not do any V/S past 2000. I know. I don't know why, but that is the way this unit works. They are supposed to do BG checks but I could not find anyone and, again, I do need to make a priority of learning who is my NA (they change 3 times during my shift).

Thanks everyone. I've been on the unit only 3 months so I'm really new to this and not sure what is a staffing issue and what is a "me" issue.

Hannahbanana, BSN, MSN

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB. Has 51 years experience.

29 minutes ago, harvestmoon said:

I do need to make a priority of learning who is my NA (they change 3 times during my shift).

It would seem that would help. Perhaps the charge nurse should assign them to rooms or nurses, and then you hand yours a list of vs, bgs, and ANYTHING within their scope with times. Then do it, and make sure they know you fully expect them to.
 
Why would they change three times in a shift? 

9 hours ago, harvestmoon said:

I gave NAs assignments at 2000 and I have no idea where they went. I wonder if they were as overwhelmed as we were. I tried at 0700 but the day NA said the night one should have done what I asked him to do and by that time I was so over everything I just did it myself. 

EXCELLENT idea about asking an NA to source flushes! The NA assignments change 3 times during my shift and I have a really hard time figuring out who is my NA so I'm going to make that a priority going forward. Also I could have Vocera'd the charge.

we're supposed to place Vascular access consults daily for the PICC patients and they order the tPa but neither patient had that ordered so I couldn't. I did place consults for both of them and let day charge know though.

Techs do not do any V/S past 2000. I know. I don't know why, but that is the way this unit works. They are supposed to do BG checks but I could not find anyone and, again, I do need to make a priority of learning who is my NA (they change 3 times during my shift).

Thanks everyone. I've been on the unit only 3 months so I'm really new to this and not sure what is a staffing issue and what is a "me" issue.

That’s crazy changing 3 times in a shift.  And I do know how it is to not be able to find your techs.  But even taking 5 minutes to search for one, grab them and just say, hey I’m really behind right now and could really use your help, will end up saving you so much time in the end.  And if I get one that sticks with me and does everything I need, I make sure they know how much they are appreciated and I pass it on to charge and my manager that they are a rockstar.  

I misswrote - they don't change 3 times; they change twice. I get 2-3 NAs though. 

Mavnurse17, BSN, RN

Has 4 years experience.

I am super impressed that you toggle all of that (seemingly successfully given the circumstances) as a NEW GRAD.  And I'm pleasantly surprised here that everyone agrees this is an egregious assignment.

My first job out of school was on a cardiovascular progressive care (step-down unit) and your description of your shift sounds eerily similar to mine, except sub some of the GI drains for chest tubes from heart transplants or CABG's, or LVADs that needed dressing changes or other troubleshooting.  I could only put up with shifts like that for so long before it really wore me down and I had to leave the bedside.  When I tried to express how hard these types of shifts were to my coworkers, they'd all tell me to get with the program and power through it-- as if it was normal to have heavy patient loads, skip lunch, and stay late to chart on a regular basis?  

You've gotten good advice here.  I do hope you can catch a break soon!

SmilingBluEyes

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis. Has 24 years experience.

On 5/28/2021 at 9:02 PM, harvestmoon said:

Last night was a *** show and I'm looking for pointers. New grad; licensed for 9 months and 3 months into first real hospital job (step down ICU). I'm also 60 years old (and I wonder if that has anything to do with it).

Our unit does V/S q.4, focused q.4, HTT at start of shift (12 hours). NAs do not do any VS other than 2000.

I had one patient who had intractable pain - narcs every hour, allergic to everything so had to manage her hives/itching reaction to the narcs with benadryl and other options. she had 3 drains (duodenal, new nonfunctioning jtube, something else and foley). POD2. PSH of several spinal surgeries and her body looked like some congenital stuff (never got a chance to check her history so honestly no clue). she had TPN, lipids, 3 different antibiotics running into a 3-lumen PICC that, by the end of the shift, had only 2 working lumens. thankfully did not have to reposition her. She had an NG and was unable to swallow (not sure of the HX there) so for PO meds I would put them through the NG and turn off suction for an hour and hope they were absorbed.  she had BG checks q.4 in addition to pretty much hourly meds/pain meds. Contact precautions and NAs never entered the room except for 2000 V/S.

patient 2 had only an ileostomy with crappy lungs. day before I had asked day shift to request CXR and RT/Pulm consult because her lungs sounded super coarse, she had a green sputum and productive cough. intractable pain and meds q.2 hours (oxy and dilaudid) in addition to her other meds. TPN with 3 rate changes during the night. PICC line with 2 good lumens. I think she had abx - don't remember. BG checks q.4 hours. NA did one of the checks.

patient 3: New admit from ER for CHF exacerbation, only had her for 8 hours of the shift. non-english speaking but had daughter to translate. She was my easiest once I spent about an hour doing the admit, setup, V/S (only twice as she was there only 8 hours), but then her BP started dumping (high 80s/40s) and I had to spend a good 30-60 minutes focused on that. 

patient 4: POD2 with wound VAC to RLE, 3 new surgical sites, q.2 hour pulse checks, abx, pain well controlled, little forgetful and confused but stable. this was my 2nd day with him and I had asked day shift the day before for lasix because his LEs were so tight, peeling and discolored I was worried for compartment syndrome (not seriously but dayum they looked awful). he was on heparin and bridging to coumadin so I was chasing his labs and titrating his heparin also. by end of shift we were down to +3 pitting edema (huge improvement from rock hard skin) on surgery leg and +2 in nonsurgical. during the q.2 hour pulse checks (I missed one of them during the night) I had to reposition him and get the surgical leg elevated.

patient 5: bariatric POD1 with N/V unable to hold down water, pain, EtOH and drug abuse HX (I found from day shift during report), but really a very stable patient. I was in there more than q.4 hours as I was staggering her meds so she could try to keep some of them down.

So, hour one (20-21) I did HTT on 3 patients and got meds up to 2100 passed as I suspected I was going to get another patient and I wanted to be ready if/when that happened. Found out about 15 minutes before tranfer I was getting the ED xfer so I was glad I had planned for another patient.

Hour 21-22 passing meds, addressing pain on pax 1 and 2, charting exceptions to HTT, adjusting TPN and replacing all tubing (expired). chlorhexidine baths on the PICC lines. Chart 2 HTTs fully.  Check everyone's labs and make sure nothing was crazy. Give insulin like candy.

hour 22-23 pretty much dedicated to new admit.

hour 23 I got 5th patient. HTT on them and keep running all the meds

hours 24-8 I'm bouncing from patient to patient. We had 2 rapids on the unit and everyone was pretty busy. Shift ended at 0730 but day shift as a whole said it seemed like many from night shift were trashed at report. I didn't start charting until 0830 as I was still responding to the uncontrolled pain patients and making TPN changes and trying to give report (we do bedside). There were 6 of us charting from 8-9 and 2 of us from 8-10. 

So, new grad, I know I'm lousy with time management but I do try to cluster stuff and anticipate *** coming up (I will dump heparin and maintenance fluids in the rooms (after say 0100 or so) so if the alarm goes off and an RN sees it they might hang the new fluid. I keep my tubing labeled and know when it needs to be changed (all TPN, lipids and abx tubing was changed so I make sure I have that *** before I leave the med room). We ran out of 10mL flushes about 5 am so I was chasing my *** on that for the PICC line patients. 

So, pointers on how I could have structured the night better?

That is not poor time management; you have had a hellish night. Don't be so hard on yourself. I hope the next shifts are better. Please give yourself a pat on the back. You did well.

renatanada

Specializes in Been all over. Has 13 years experience.

Sounds exactly like the progressive care unit I work on. My last shift is coming up. It's unsafe. Hate it. There are so many better nursing jobs out there. Don't believe the "hero" rhetoric. Get out! And become an NP as soon as you can. 

RN-90

Specializes in Womens health. Has 31 years experience.

Hats off to you for surviving this night!  Five is too many patients for step-down especially when they all sound quite ill.  It sounds like you have done many things within your power to help the situation.  If these are the unit expectations to manage 5 patients, I might look elsewhere if things don't change.

 

cgw5364

Has 33 years experience.

That's the kind of night you pray everybody just lives until morning and pray you don't make a mistake. Many nights on Oncology were crazy like this and I would be at the desk charting for 2 hours afterward. This is from a 30 year nurse. The last 10 years of my bedside nursing career was in mother/baby and even though the patient were not "sick" there would be nights just as crazy with 4 fresh C/S mothers and newborn couplets to care for. Sometimes I was the only RN with two LPNs who were wonderful but I had to handle all of their med pushes and had charge duties in addition to my own patients.  Frankly I am glad I left the bedside 10 years ago for audit and denials work. I still have nightmares where I am working as a floor nurse and "forgetting" to take care of a patient for an entire shift. This never actually happened to me but it was one of my biggest fears as a nurse. 

Mavnurse17, BSN, RN

Has 4 years experience.

16 hours ago, cgw5364 said:

I still have nightmares where I am working as a floor nurse and "forgetting" to take care of a patient for an entire shift. This never actually happened to me but it was one of my biggest fears as a nurse. 

I have dreams sometimes that I get to 0700 and realize I forgot to give a single medication all night 😥