Being a new nurse is stressful, but my employer has provided me with some great tips for success. These tips can also be used during clinical rotations. This plan will help you to be organized and give you the ability to create an efficient plan for your shift.
1. Door assessment
Introduce yourself to the patient and explain you're going to get the shift report. Make the conversation short and sweet, don't dwell. This introduction will allow you the ability to "see" your patient (aka door assessment). You CAN'T ask questions if you DON'T know the inconsistencies. If you see a wound at the time of introduction, you can ask follow-up questions during the report. Shift reports are usually based on the patient's medical chart, the nurse's notes, memory, and/or experiences during the shift. Sadly, sometimes specifics are omitted (not intentionally). The shift report should include physical findings, surgical details (if applicable), physician notes, and/or diagnostics details. These topics will give you the full picture of your patient's medical condition. Once you have this picture, you can then determine if the information given during report matches the clinical picture you initially observed.
2. Critical is the name of the game
After you have the visual (door assessment) and have obtained the shift report, it's time to find out which patient is MOST CRITICAL. Which patient do you want to perform the assessment on first? The patient that presents as hemodynamically unstable (remember, ABCs). Your first hour should be centered around doing your assessments and finding out your patients' needs. Airway, breathing, and circulation (ABCs) are priorities within inpatient medical care. But as we all know, there are primary and secondary surveys that also need to be addressed. Work your way down the alphabet, making sure you've addressed all areas of concern. Oh and don't forget those five, or seven or whatever P's (HCAHPS style). Safety is of the highest importance, don't forget.
3. Two-hour short term goals
Once you have your assessments and the medication schedules in order, start to plan your day. Make SHORT TERM GOALS in two-hour increments. For example, from 8:00AM-10:00AM: I will do all my assessments, assessment charting, and give my morning medications. If you don't have goals, you'll continue pushing incomplete tasks further and further behind. As there is no timetable to reflect and reassess upon. It is in my opinion that small amounts of pressure are healthy. They allow you the ability to motivate yourself. It will be overwhelming at first, but you'll get into a rhythm and find your groove. Throughout your day, keep planning events in two-hour segments. This strategy will keep your organized and prepared. We all know nursing isn't this simple but with a plan of action, your won't have to depend on your memory resulting in things falling through the cracks.
4. Documentation sheet
Creating a proper documentation sheet is of the utmost importance. You can't track your short terms goals without it. When you're scrambling around, doing your assessments, administering medications, giving baths, and performing tracheostomy care, you will need an old-school method of tracking your progress. Yes, electronic charting of these interventions will need to be done too. But this approach is for personal tracking, not legal documentation purposes. Cellular phones, computers, and smart watches are exceptional devices that do an abundance of tasks. But, nothing beats paper, pen, and checkboxes. People underestimate the power of utilizing pen and paper. For documentation sheet examples, click here.
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