1st Year Nurse Tip 1: Be Early

Inspired by a few of my friends, who just finished nursing school, and passed the NCLEX, I’ve decided to write a series of post’s titled, 1st Year Nurse Tips. While I did receive tips here and there, from some of the nurses I work with, I had to learn much of this on my own. Don’t get me wrong, there’s no manual available that cracks the code for how to be a good new nurse. Much of it simply comes with time and experience. But, there are many things I learned along the way, in my first year as a new nurse, and mistakes I made as well, that taught me a lot. Perhaps, my mistakes and lessons, can help guide you, in your first year as a nurse. So, here goes!

As a new nurse, it’s so easy to get behind, even before you’ve started your day.

I suggest having scrubs, shoes, lunch box, nurse bag etc., ready to go the night before.

Get up early, for breakfast or a coffee. I splurge and run through Starbuck’s, using mobile order for speedier service, so that when I arrive at work, I can look through my charts leisurely, with a coffee in hand. It’s kind of a little reward for working hard, and being up early, or at least that’s my excuse. Or, you can sprint through the hospital cafeteria for a free cup as well.

I arrive at work, and I’m sitting at a computer station, about 20 minutes prior to the morning huddle. Being that early, allows me time to look at my assignment for the day as well as look through each of my patient’s charts. Some may think I’m too involved in the process of looking things up. Perhaps I know more then necessary about my patients, but is that possible?  I can say this, before I even begin report with the night nurse, before I speak with the physician’s during morning rounds, before a family member or patient asks me for a status update, (most of the time) I already have the answers.  I’m already aware of the plan. Being informed about my patient’s, being ready for my day and being ready to answer all the questions that come flying my way throughout the shift, helps me feel in control. As a new nurse, one doesn’t always feel in control, but this is a way in which you can take hold of your day and run it, as opposed to letting the day dictate and run you!

To further explain my process, I’ll disclose exactly what I look up in the charts and why, in this post.

First, I look at basic information:

•Name

•Age

•Allergies

•Admitting Diagnosis

•Doctor

•Consulting doc’s

•Code status

Next I peek at the H&P or if that’s not yet available, I’ll look at the Emergency Physician’s notes. From these notes I gather information about:

•Reason for visit

•Medical History

•Social History- does patient smoke or drink?

•Psych History

•Living situation. Does the patient live alone, with a spouse, with a family member, in a home, or in an ALF?

•Doctor’s Impression

•Plan of care

Then I peek through all the Physician Clinical Notes, and Consult Notes. I don’t necessarily read every last detail, but I place most focus on the Impression and Plan for the patient, and any new developments. These notes allow me to peek into the mind of the physician’s, so that I gain a better perspective of his/her plan for the patient. It’s very helpful when a doctor approaches me, and I know exactly what he/she is thinking. Now (a year later), I can almost anticipate what the doc may say. Most doctor’s carry respect for nurses who do their homework, and think ahead, because that puts everyone on the same page. It’s much more efficient this way. Also, if I feel something has been omitted in the plan of care, or the orders, then I’m better prepared with all my questions and suggestions when the doc arrives on the floor. Sometimes at this point, I’ll also take a quick peek at the Ancillary Notes, for specific recommendations by PT for discharge, or notes from the Social Worker about placement etc.

Oh, and one more thing, as I’m looking through the physician notes, I also take note of wether or not the patient qualifies as a Core Measure patient. If the patient’s diagnosis reads Stroke, CHF, COPD, MI, Pneumonia, and SCIP, then there are protocol’s and requirements in place, that must be met on admission, during the stay and prior to discharge.

Labs and Diagnostic Test Results follow. At this point I look through:

•Lab’s

•Diagnostic Test’s and results

•Cardiology documents such as EKG’s or 2D echo

•Operative Notes

•Recent vital signs and trends

•And, any other significant testing that’s been done, such as EEG

Next, I look through all my orders, taking note of:

•Patient activity

•Diet

•Pending and Completed Diagnostic Tests

•Labs, and wether or not there are any pending ‘nurse draw’ labs

•Consult’s- Pending and Completed. If a consult is pending, and it’s been over 24 hours since the order was placed, I’ll need to follow up and call the consulting doc.

•Meds

•Special Physician to Nurse notes or instructions

•Consents that need to be signed

•And the basic’s-

  • How often are vitals?
  • Strict I&O?
  • VTE prophylaxis- SCD’s, Lovenox or low risk
  • Telemetry or not?
  • Fluids?
  • Tubes? Such as foley, PEG or NG.
  • PICC line —> CHG Bath?
  • NIH? When’s the next one due? At our hospital, NIH is done on arrival, 24 hours after the first one, any change in neuro status, and at discharge.
  • Dressing change instructions?
  • PT, RT, OT, ST or Home health consults?

Lastly, I look at the MAR, or the medications due. I ask myself:

•What are the med times? I write out all the med times in red on my report sheet, as a reminder of when meds are due for the day.

•Are there PRN meds? I look to see if the patient has received any PRN meds during his/her stay. If so, then I calculate the next time the med is due. If not, then I just make note of what’s available in my toolbox, in case the patient should need it. Pay special attention to certain PRN meds that MUST be given, under certain parameters. For example, Potassium is sometimes listed under PRN, with the parameters that the nurse should give Potassium for a K+ less then 3.4. Also, there are often times PRN blood pressure meds that must be given, if say the SBP is greater then 170. You must not miss these, because even though they aren’t scheduled, they sort of are, because they must be administered under certain circumstances.

•Are there Continuous Fluids to be given? I look for continuous fluids, and I note the type and rate.

Ok, I think that may be enough information for today.

Be prepared for your day! Start as soon as possible. Never take the attitude that you’re day will be easy, even if all your patient’s are under 50, only have 9 am meds, are independent and have zero “involved” family members. You can never know if your day will change. Get started right away, and finish charting like your life depends on it, and try and do this before noon! Then you will be prepared for any changes in your plan, or any hurtles that come along. Believe me, at any moment you could be calling a stoke alert,  or a code blue, grey, or brown. Any one person can receive a terrible diagnosis and need a hand  to hold, or a listening ear. At any point, all your young independent walkie talkie patient’s could be discharged at the same exact time, and each one wants to leave prior to the one next door. Then, guess what? If you’ve discharged all your patients, there will be admits, and perhaps these new patients won’t be as easy as your last crew. Perhaps you’ll be bombarded with loads of questions from scared family members, who wonder if their loved one will recover from the stroke. You just never know how your day will present. And, if you get lucky, and you’re sailing through your day with extra time, help another nurse. There is alway someone who needs your help, someone who’s drowning. Passing meds on one patient for that overwhelmed nurse is huge. It’s not a big deal to you, but for the nurse who’s overwhelmed, it’s a big relief. You never know when you’ll be in that space, needing  help from another nurse.

Be ready! Have a plan. Attack the day right away, in anticipation of loads to do,  because you never know what the day will bring!

 

 

 

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