What are your routines like on a medsurg unit

janleb · Apr 16, 2004

One thing that is not routine is your patients. I usually work 3 twelve hour shifts in a row and most of the time have the same pt. I always assess my pt as if it is the first time I have taken care of them. Pt conditions can change very quickly.

1. Get report I keep my previous report from the following shift I worked for comparison. (I usually xerox the kardex and write in red the report I get and in green anything I want topass on to the next shift, saves me time. )

2. My most serious pt I assess first, fresh postop ect. by just going in and saying hi, get a look at the fluids running Ivsite , foley output good , pain level and concerns pt may have, any mental status change ect.

3. Take a look at the mars

4 report to my nursing tech any concerns I have and to make sure we are on the right page as far as pt care , accuchecks ect.

5. I found trying to be proactive , saves a lot of complications. Know a pt history , for instance I don't know how many times I have had pt with a hx of CHF and had fluids running 125, and out put not good and respiration becoming labored, ect. things that are very preventable.

6. Just don't get in the habit of just because you have the same assigment the asssessment will be the same. We assess pt every 6 hours. With that kind of thinking you are putting your pt and your license at risk.

7. And inbetween all the routine things expect new orders so make sure you check, also make sure equipment that is ordered is in use.

Long winded I am but I hope this helps

janleb · Apr 16, 2004

also don't forget labs and compare to the previous day. Any thing that is abnormal report. Many time I will call the physician just to give him a heads up on the pt condition even if nothing is ordered. Most docs appreciate this.

angelique777 · Apr 16, 2004

also don't forget labs and compare to the previous day. Any thing that is abnormal report. Many time I will call the physician just to give him a heads up on the pt condition even if nothing is ordered. Most docs appreciate this.

this is basically what I see on the unit. When you are knew on a unit it is hard to see what are all the things the nurse does or all her thoughts but I see the patient is monitored. All the things you mentioned are pretty much what has been done

I just wondered if the assessments where complete head to toe each morning it just seems that this would be impossible

However I do understand everything you explained most definitely it helps me think about everything especially your point about the IV fluids and CHF patients very important point..

Next week I am hoping to have my preceptor assign me two patient for me to care for completely to see how my day goes then increase it to three and see how it goes.

So far I have given meds to all 8 patients and kinda monitored to see how things are but I will get a better feel when all the responsibility of the client is on me this way I can see the whole picture

I hope I get more responses can an idea on how each person thinks about there day really helps me approach my day better as a new student helps my thinking I appreciate the responses and hope to get more

take care Angela

Long Term Care Columnist / Guide · Apr 16, 2004

I generally do focused assessments, unless of course I have a new admit, who gets the full head-to-toe treatment. There simply isn't time to do full assessments on that many patients, and no one really expects you to. When I start at 3 PM, the afternoon assessments are usually done, but since I need to know myself how the patient is doing, I'll focus on their main problem, e.g. CHF (listen to lungs and heart, check urine output and edema etc.) or bowel obstruction (abdominal pain, distension, presence or absence of bowel sounds and their characteristics). I also assess their mental status, check their IV site and O2, any tubes or drainage devices, dressings etc., and ask them about their pain.....and all this takes maybe 2-3 minutes. (Don't worry, you'll be able to do this with practice!)

Later on, if I keep the same group of patients after the 7 PM shift change, I'll do more in-depth assessments where the situation calls for it; an example would be a post-op patient whose urine output isn't picking up after several liters of IV fluids. That's when I need to check the feet, legs, sacrum etc. for increasing edema, listen to the lungs, belly, and heart, and evaluate the overall picture: where is that fluid going? What's the pt's history---is there CHF or renal insufficiency? Is it my imagination, or is that belly swelling? Oh look, the Foley's kinked!! :chuckle (That actually happened when I was a new nurse :imbar ........now I know to check the catheter BEFORE I call the doctor to report low output.)

allnurses Guide · Apr 16, 2004

I work 3 a.m. to 3 p.m. After report we check our MAR's, charts and meds and labs for the day. I check the times I need to give meds on my little cheat sheet. We start assessments with the 0400 vitals. We always go in with the CNA's so we don't wake the patients twice. Most have to be weighed, either stand up or bedscale. Most patients head to the bathroom or bedside commode. I can do alot of my assessment during this time (skin check, pedal pulses, A & O, etc) and I do a full assessment. Then back to bed. My assessments are usually done and charted by 5 a.m.

We start vitals again early about 7:30 so we can have that charted before the docs get there.

steph

angelique777 · Apr 16, 2004

I generally do focused assessments, unless of course I have a new admit, who gets the full head-to-toe treatment. There simply isn't time to do full assessments on that many patients, and no one really expects you to. When I start at 3 PM, the afternoon assessments are usually done, but since I need to know myself how the patient is doing, I'll focus on their main problem, e.g. CHF (listen to lungs and heart, check urine output and edema etc.) or bowel obstruction (abdominal pain, distension, presence or absence of bowel sounds and their characteristics). I also assess their mental status, check their IV site and O2, any tubes or drainage devices, dressings etc., and ask them about their pain.....and all this takes maybe 2-3 minutes. (Don't worry, you'll be able to do this with practice!)
Later on, if I keep the same group of patients after the 7 PM shift change, I'll do more in-depth assessments where the situation calls for it; an example would be a post-op patient whose urine output isn't picking up after several liters of IV fluids. That's when I need to check the feet, legs, sacrum etc. for increasing edema, listen to the lungs, belly, and heart, and evaluate the overall picture: where is that fluid going? What's the pt's history---is there CHF or renal insufficiency? Is it my imagination, or is that belly swelling? Oh look, the Foley's kinked!! :chuckle (That actually happened when I was a new nurse :imbar ........now I know to check the catheter BEFORE I call the doctor to report low output.)

Wow you cannot imagine how much this has helped me. I am learning so much by reading what your day is like . Really helps me think better and realize how to start my day next week. Based on you replys I am going to approach my day very differently..

We are on a computer system so that helps a lot all patient information on computer not on card however one hospital that I may work at has those cards so it is important for me to know.

What is MARS not sure what that abbreviation means .Sorryfor my novice ingnorance.

Gosh I am enjoying reading these replys

Hoping to read more. Its so helpful

Thanks again

nursenatalie, ADN, RN · Apr 17, 2004

oh, a MAR is a medication administration record. The one thing to remember is that there is never a strict routine. I ALWAYS give my patients a full assessment, this may not be possible at beginning of shift, I try to make sure everyone is pink and breathing at beginning of shift maybe check some fresh surg. sites etc. Then I will go check meds and begin assessing pts based on accuity. There are times that my post-op day 4 patient may not get a full assessment until I have been there four hours but I have been in the room checked IV site/fluid etc. and vitals but I have to document on lungs/bowels/CRT/skin integrity so you better believe I assess it!

RN-PA, RN · Apr 17, 2004

I work med-surg 3-11 (1445-2315) shift, and I'm always looking for ways to use my time well. If the 7-3 nurse is late in giving me report at the beginning of my shift, I'll start checking charts and/or going through the medication kardexes and begin writing down when all my meds are due. If I see that patients have INT's (heplocks) or PICC lines, I may begin filling syringes with NSS and putting them in their med drawers while I'm waiting. I work part-time, so I rarely get the same patient assignment 2 nights in a row, so I'm frequently "starting from scratch" each time I work. If you get the same patients a few days in a row, it'll help you because you'll know how best to organize yourself-- when the most meds are due, when a patient prefers his wound care, this patient needs his heparin gtt renewed daily, etc.

After report, I do quick chart checks on my 4-6 patients (if I only have 4 patients, I will usually have at least one more patient assigned-- admission, post-op, or transfer before I'm out of report, and a total of 6 by the end of the shift.) I then go through all the med kardexes and write out when meds are due in columns from 1600 to 2200. (I just write room # and "PO X 5", "SQ Hep", "IV Ancef or IV Lev"-- abbreviations to give me an idea of what's due) I gather any 1600 meds, and will see either a patient who has an IV piggyback med due or the patient(s) with highest acuity first, as others have mentioned. Since dinner comes at 1700, I try to get as many assessments done between 1600 and 1700. If I have an NPO or tube-feeding patient, (and they're stable), I leave their assessments for last. If I'm REALLY swamped, I say hello to patients whose dinner's arrived and promise to assess them when they're done (after asking if they need anything). At some point in this first hour, I give a quick report to the PCT I'm working with and will delegate anything I can to her at that time. I check over the vital signs and write the temps and BP's on my report sheet, as well as accuchecks of all my patients if she's obtained them by that time.

As you get an assessment routine down and become more comfortable, you will learn to do two-three things at once. While you're assessing their orientation, you can be checking pedal pulses and edema; as I'm introducing myself, I'm checking their IV fluids and their IV site, maybe hanging an IV med. Listen to heart, bowel sounds, lungs (check sacrum and skin while they're lying on their side), check incisions, wounds, etc. Check urine output, remind patient to use urinal or "hat" if on I&O, ask about pain/nausea/SOB/DOE. Check O2 and do a pulse ox. I write my ABNORMAL findings only on the back of my report sheet and will document them on the computer when I have time (sometimes that's at 2330 or midnight...) With 8 patients, you'll have to do more focused-type assessments as others have mentioned, to save time. If I have a chatty patient, or as I'm doing teaching, I'll tidy up their room-- fold a blanket, throw away excess cups, take out their leftover lunch tray, make a neat stack of newspapers. This is ONLY if I'm not crazy-busy at the beginning of a shift (rare), but I'll neaten up at some point during the shift.

I sometimes combine 1600 and 1700 meds if it's really busy (and depending on what the meds are), and I'm always trying to combine trips to the med room and save time by making a mental list or quickly scribbling all the things I need to save a trip: 302-1-- juice. 304-1-- Percocet & denture cup. 305-2-- IV Ancef/IV Flagyl. I also make a list of things I need to remember to do at the bottom of the sheet where I have my meds and times due listed like: 310-1--PTT at 1800/Coumadin order. 310-1-- sleeper (means I need to order a sleeping pill when house doc comes on at 1900) 308-1 check pulse ox at 1900. 308-2-- pre-op teaching.

I keep a list on my clipboard of frequently called extensions so I don't waste time looking for phone numbers. And all I've mentioned is just a basic "structure" for my routine. It all goes out the window, of course, when you're calling docs for problems and orders, hanging blood products, helping the LPN with her needs, walking people to the bathroom, running for pain meds, taking report from PACU on your post-op or from the GI lab about your patient's colonoscopy, talking to family members, taking off orders, etc. etc. etc.

J Lynn · Apr 19, 2004

Bump............................

janleb · Apr 20, 2004

You will be amazed how fast a head to toe gets when you have been doing it for al while. fore example as soon as you walk into the room. Introduce yourself

dialogue might go as such hi I m your nurse today my name is Janice and you are.......... Don't say are you mary smith I have had confused pt say yes I am. Boy ms Smith how many days have you been here???? are you feeling better than yesterday (that opens up dialogue to any subjective changes that the pt may have. When I ask about where a person is I usually say I ask these questions because some of the meds you are taking can cloud your thinking, Especially with the elderly that are completely alert and oriented are not affended by there mental status being scrutinized. just look around the and get a eye vew of iv infusing any swelling and fluids at the right ratet rate. Foley andy other tubes ect by just glancing as you are talking. Mind you there are certain days when a "comlete" head to toe are not like in the morning so I sometimes listen to lungs , mental status, major reason why pt it here. dsg dry and intact, do any central line dsgs need to be changed, check I & O for the last few days to reduce risk of overload and check for edema in lower extremities. One thing I always do at first thing is check the pt histroy and physical for previous conditions.

J Lynn · Apr 20, 2004

I love reading about how other nurses organize their time. I'm definitly taking notes from this thread. I want to work Med/Surg, but i'm terrified that I fall behind. In clinicals, I fall behind with 1 pt. Of course, all the other students and my instructors are always getting me off track. I have trouble multi-tasking sometimes. Need to work on that.