Thursday, February 28, 2013

What Do I Do?

I started this post over a year ago, before my facility transitioned to electronic charting. My routine has changed slightly since then, but this is still a fairly accurate description of the first half of a shift, using paper charting. I don't have time to finish the shift here, but maybe I'll write a current complete description someday...

"So, what do you actually do at your job?"

With so many images of nursing prevalent in our society, it's a valid question. I hadn't considered the general public's concept of nursing until asked this question by a young friend. I had operated with the unconscious assumption that "I'm a nurse" adequately described my professional activities. Of course, it doesn't.

The best way to answer this question for my young friend was to give a rough sketch of the day's activities. But any nurse will tell you that the tasks are not the whole truth of what a nurse does and gives for his/her patients. The emotional energy to be cheerful, the act of listening listening, acting with compassion, the fatigue and frustration take a toll also.

But all that aside, here's a brief sketch of a "good" routine day on the unit.

0650 - Badge in at the card reader. Walk to the unit, stow lunch in the fridge, wash hands. Load pockets with alcohol wipes, pens, penlight, bandage scissors, note pad, prompt card for the unit phone number and other important notes. Fill out a report sheet with an entry for each patient including age and room number, diagnosis, doctor, allergies, diet, supplements, activity level/restrictions, any tubes or catheters, IV fluids, lab work for the day, appointments for the day, and special considerations based on the Kardex entries.

0710 - Get report on each patient from the night nurse. Includes general information about the patient, significant events from the past shift and things to be aware of for this shift, as well as significant patient assessment data and doctor's orders.

0730 - Go check my patients. If they are sleeping, watch their breathing for rate, depth, regularity. If they have any monitoring equipment, record data. Print telemetry strip for any patients with heart monitors. Invariably one of my patients at least will be awake. I introduce myself and ask if I can listen to their heart and lungs. I listen to lungs, heart, abdomen. I feel pulses in arms and feet, look at any dressings, look at eyes and mouth, and generally watch to see how alert and "with it" the patient is. Ask the patient about any pain, turn and reposition him or her, and address any needs or wants of the patient at the moment. Then I move on to the next patient. If I have time, I write all these findings down on the patient's assessment flowsheet. If not, I quickly check the boxes next to the significant findings and go to the med-room to prepare for med pass.

0800 - Routine medications can be given within an hour before or after the time at which they are scheduled. 0900 is the biggest med pass of the day because almost all the "daily" medications are given at this time. With an average of 4-5 patients to a nurse on a "good" shift, administering all the medications within the 2 hour window can feel like a race. Each patient's medications are obtained by accessing the Pyxis - a locked computerized system of drawers and cubbies which only open when an authorized user with the correct password select the appropriate medications loaded in a particular patient's profile.
Once the medications are obtained and checked against patient name, date/time, specific med and dose, and prepared (by drawing up medications from vials into syringes for IV, intramuscular or subcutaneous injection), I go to see the patient in question, again checking the medications against the Medication Administration Record or MAR and the MAR against the patient's wristband and verbal answer to name and date of birth. If I've assessed this patient earlier, I follow up on any questions I have left regarding the patient's condition, current needs, and do a brief visual assessment of the patient and the environment (Is the bed wet? Is the bed alarm on? Does the patient seem confused? Is any equipment attached to the patient functioning properly? Are there environmental hazards I've overlooked, like wet floor, sharps not disposed properly?). All this can be done during actual med administration. If I haven't assessed the patient earlier, I do this now. If the patient has simple wound dressings and I have the proper materials, I may change the dressings at this point. Complicated or time consuming dressings I leave for later in the shift. During med pass, I explain to the patient (within the limits of each person's ability to understand) what each medication is for. That way, if I have time for no other education, at least I've reinforced an understanding of each person's meds, and sometimes this will earn me a little trust from the patient.

After I've made sure that the first patient's immediate needs are addressed, and that he has his call light, I move on to the next patient and repeat the process until I've passed am meds to and assessed all my patients. On my floor I've had anywhere from 3 to 6 patients at a time, depending on staffing and patient census levels. But hopefully, I organize myself so that all my patients have their meds by about 1000.

1015 - I try to take a break and tick of the assessment boxes for each patient, maybe start a little of my narrative charting. The earlier I do it, the more time I will have later and the earlier I will be able to leave after my shift ends. It's hard to write down everything that has happened - but only the important stuff. I also have to work around patient appointments, physical/occupational/speech therapy sessions and off unit treatments like Hyperbaric Therapy or Dialysis. And patient families.

Patient families are a joy and a dread. They are your best ally or your worst enemy. They can take a huge load off your shoulders or eat up hours of your time with triviality. And as a nurse, you have to deal with them. You don't really have a choice. But I digress.

Between 1015 and 1100, I do as many dressing changes/ treatments as I can and chart as much as I can. Because at 1100, another med pass begins.

1100 - Rush to check diabetic patient and feeding tube patient blood sugars. Give meds now if possible. Often the patients don't return from physical therapy until just before noon, so blood sugar checks can be a bit challenging. Lots of Zosyn IV piggybacks to hang.

1200 - trays arrive in a cart. Unlike "the big house" as the main hospital is called, we don't have hospitality people to serve individuals lunch. Nursing has to distribute trays; usually the aides do it, but I try to pitch in, especially if we have too few aides that shift. Between setting people up for lunch and giving medications, I'm usually still running after this and that. 

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