i’ve got four patients last night. there wasnt much of any challenges or interesting facts over the entire night. in fact, it was pretty quiet.
my daily routine starts out by getting report from the day nurse. i hate kardex’s since they always prove useless to me since i still have to go to the chart anyway to do a 24 hour check. i also read transcripts from doctors since it is easier to read than their chicken scratch handwriting on the chart. sometimes i think they should be liable to how they write but then again thats a different topic.
after i get the pertinent info about my patients (name, age, doctor, diagnosis, diet, iv fluids, activity, current status, etc), i start by taking their vital signs and doing my general assessment. It takes me 5-8 minutes each patient for the complete assessment of ambulatory patients, 8-12 minutes for bedrest/very weak patients and sometimes 15-20 minutes for patiets who are either grossly obese or is a complicated case (several tubes, IV’s, isolaton, vasoactive drips, restraints, etc.). My assessment includes full body assessments, noting the general systems, iv status, pain status, any tubes, iv drips, skin & fall risk asseement. After assessing the patients, if the patients have no pertinent or immediete needs, i chart my assessments. then i start out looking at their charts to check recent orders and carrying them out if needed.
luckily last night everything wsa done except for a couple of consent forms to be signed, plavix to be given as a pre-op med for cardiac catheterization and hanging of iv fluids that are almost finished.
medication pass starts at 9pm but i started out at 8:50 last night. checking the 5 R’s (right patient, time, dose, route, medication) is very important to me. i carry the mars with me and check their armbands too. these mostly cover up my time till the next vital signs are to be taken. I had to call pharmacy a couple of times to correct some medication issues such as missing medications and incorrect medication dosage entered in the pyxis. it was a near miss incident since i could have given a double dose of cardizem bt as i have saig, it was caught and was a near miss situation instead f an incident report.
In between giving medications, patients needed to be taught about their expectations on the upcoming procedures, assist them in their toileting needs, inseritng IV’s (which i did twice last night), and if someone is in distress (thank goodness nobody was in that position last night), i will have to take care of that too. As i have said earlier, it was pretty quiet for me so i finished my med pass as half past nine. then i dcisded to check teir labs, radiology reports, history, plan of care and doctors transcriptions of procedures and consults. this things are very helpful to me during my shift so i can understand better what their symptoms are telling me.
11:30 is the mark for my next vital signs. i also give out their midnight medications at this hour and check if any patients needs their sleep aid medications if indeicated in their charts. i briefly assess them during this time focusing on the symptoms for their diagnosis. I make it a habit to chart after all of this has occured so i wouldnt get behind on my charting.
then, it is time for 24 hour checks making sure their admission status is up to date, orders have been taken care of, medications have been signed and given. then we take or lunch break. this is the time when it gets really slow unless our patient are having distress.
afer this had all been done, we do our hourly nursing rounds until it is time for the 3rd vital signs. at appoximately 3:30 am, i start doing their vital signs and their wieghts. after this chart again (did you notice that we cart a lot?…yea…we are too liable to a lot of things and as they say in nusing school, at work and probably in court, you didnt you do it if you didnt chart it.
5:30 is the mark for gathering 6 am medications but since our monitor tech went home early cause she was sick, i rotated with the chrage nurse to be at the monitor room. my patients are pretty mucjust sleeping away and their IV fluids are all set for the next bag. nobody had 6 am medications.
0620 cath lab called toask if patient 4 is ready. i informed the patient of the intent and was okay about it. she told me to notiy a friend about it and proceeded to brush her teeth while waiting for the courier.
0630 they came to get patietn 4 and patient 2 is now asking for pain medication.
after all of this has been done. we gave report and proceeded to go home!