Getting Organzied
I can’t believe how unorganized I had been before! When it comes to clinicals that is.
So, in first semester, they gave us a CPT or a Care Planning Tool. It was like 3 pages stapled together and it ran through the whole assessment with blocks for you to fill in. It had Vital signs, then areas where it asked about GI/GU, Cardiovascular, Respiratory and so on and so forth. On the last page you filled in your nursing diagnoses/interventions/etc.
After 2nd semester, they weren’t mandatory each week. We started printing off the nursing rounds reports and using that. I’ve asked a few others and it seems like everyone pretty much gave report off of whatever popped in their head and we just wrote down a long list of everything that we heard. It wasn’t very concise or organized.
Example of the poor/former way:
“Here is Mr. Jones in room 5555. He was admitted for R knee replacement. He’s been doing pretty well today- his wife is at the bedside. He’s got a PCA pump and PT/OT should be coming around after lunch. Um, what else? Oh yeah, he’s got the polar ice machine by the bed. He uses the bathroom on his own and his wife helps him. His last bowel movement was yesterday. His diet is regular. He’s been appropriate, everything sounds great. Yeah, pretty good patient, you should have an easy day. Alright, see you tomorrow!”
My sheet would look like this:
- Mr Jones room 5555, R knee replacement
- PCA pump
- PT/OT after lunch
- wife at bedside
- polar ice
- regular diet
- bathroom on own
- appropriate/clear
I never understood why our reports took 2 minutes when the nurses took 15.
Now I know to go system by system. It’s more accurate, especially when your patients are sicker.
My sheet gets set up like this now:
Hx:
Neuro Resp Cardiovascular (CV) GI/GU
Neuro: were they appropriate, headache, cough/gag reflex, pupils, muscle strength, hand grips, dorsiflexion/plantar flexion, level of consciousness (LOC), increased cranial pressures (ICP…more in the intensive care units)
Resp: average rate, work of breathing (WOB)- any nasal flaring or grunting, lung sounds bilaterally, any treatments such as albuterol, oxygen needed if any, trach, frequency of suctioning, secretions
CV: max temp, average temp, ranges for heart rates and blood pressures (so you know their baseline), pulses, edema, murmurs, skin temp warm or cool, cap refill, arterial or central lines if any (more for ICU)
GI/GU: diet, tolerating well or not, route of excretion whether its voiding or catheter or ostomy, strict Is/Os, what output has been like, are they getting up to the toilet or using bedside commode/urinal/bedpan
And then you can add any notes like wounds, special requests, what treatments need to be done, what tests have been ordered. We also go through and check orders and meds so the next nurse or you know whats being given and why and if you disagree with something, that’s when you can go and talk to an MD about it.
I feel so much more organized now! It also helps with your charting when you get report like this cause you already have the whole picture in your head of what you’re looking for. Before, I used to start charting and forgot to check something and have to run back in the room or do my whole assessment with my CPT. Now, I don’t b/c everything is already on your brain. The girls in my class also doing PNA have experienced the same thing so at least I know I wasn’t behind before or anything. Anyways, hope it helps! If not, what works for you?
Love,
Laney
