[One of the many great submissions to the Those Emergency Blues Prize for Writing. Posted here with permission.]
Author: Sean Dent
Blog: My Strong Medicine
We Do More In Our First Hour Than Most Do All Day
I think we nurses should start advertising our skills like the Army does. You know that commercial or that saying about those in the Army do more before 6am than most do all day.
(As a side note: I tried to find that commercial with no luck.)
OK. So maybe it wasn’t the Army? It was some branch of military darn it!
I thought I’d just highlight the first hour of a nurse working at the bedside in a hospital. I’m going to be a lil biased and use a nurse working in the ICU (sorry).
Most nurses arrive 15 minutes before their shift just to brew their coffee, change their clothes (shoes mostly), gather their needed equipment (clipboard, stethoscope, pens/ pencils/ markers, scissors, etc.), get a lay of the land (in the break room and also out on the unit), prepare their day ahead (priorities), put their initials on and stash their lunch, use the bathroom (since this might be the last time you get there for quite a long time), do their hair / makeup (no – not me), and any other sidebars before they actually clock in!
Oh wait I forgot. Most of us will still prepare ahead of time. We either have pre-printed report forms we write on during report, or we go to the computer and print out our report sheets, also print out a current census sheet and also view the staffing for the day to determine that plan of action.
Who’s here, who’s not. What’s the staff :patient ratio today? (yes, it will vary in some organizations) This is always about how understaffed the unit could or could not be.
OK.. Back to clocking in
Assignments and staffing
Staffing is assigned (or a vague attempt). Most of the time we try to be fair and even (when I say ‘we’ I mean the charge nurse with the input of the other staff nurses). If you worked the prior day we try to line you up with the same assignment (although that can change at the drop of a hat). Is there a secretary? What is the skill mix of today’s staff versus the complexity of the patient load? What is the severity of the patient illnesses(ventilated / hemodynamic monitoring /etc.)? Is there newer nurses who need experience? Are there orientees with preceptors (no preceptors)? Which patients have procedures and road trips? Any with multiple procedures? Surgeries today? Incoming and outgoing patients? Also what is the length of every staff members shift for the day? Who’s here for 8hr? 12 hr? Who’s coming in and when? Wait, are there student nurses visiting the unit today?
This is where the ‘big picture’ is put together for each patient that you are assigned. Everything from admitting diagnosis, days on the unit, severity of illness, road of recovery, treatment plan, etc. All of the information needed is more than likely in numerous places. What is allowed, not allowed? Diet – fluid restriction / special diet / diabetic? Patient toileting needs (foley, voiding, assistance). Contact information allotment for change in patient condition as well as consents for procedures. What services are on this patients case (multiple medical services as well as primary care – ortho, surgery, pumonary, etc) What is the patients code status (full code? DNR?) Current therapies – everything from occupational and physical therapy to intravenous fluid status and needs. Any special precautions taken – is the patient in contact / droplet precautions?
Patient history – everything pertinent to their care. Allergies? Past medical illnesses? Past surgeries? Any and all of these findings will change and direct your care. Patients age is also pertinent to the customization of your care.
This is also the time to review all pertinent labs in regards to the patient. What’s normal? Abnormal? Why and why not for each finding. What to do about all your findings? What has been done for the lab values, what hasn’t been done. Who needs notified?
This can be nurse to nurse, or a pre-recorded message. This is where the previous shifts activities are reviewed. This is when you compare what you know, what you expect to hear, what you expect to find with what actually is happening to the patient. What you read on paper and on charts never tells the full and accurate story of their care. EVER. Listen intently and list anything that is pertinent to your days activities. There are so many things to note during a report that they are too numerous to list. The bottom line is to extract every finite detail to try and prevent any mistakes during the application of your care, as well as customize what you do towards your patients needs
If you listened to a pre-recorded report you would then follow up and get any additional updates and have any questions you may have answered with the previous shift nurse.
This is where…
Oh wait. I think I lapsed past the first hour already? Whew…
I left out so much. I know I did. I tried to envision me at work, but there is so much that happens behind the scenes and ‘automatically’ that I can’t account for it all.
The message here is we have so much to do in such little time. You wonder why we nurses arrive early, cheat and prepare before we clock in??
That whole time management thing – yeah we got it.