First day on the job without your preceptor? Congratulations! This day has been long in coming!
It’s important to manage all the interruptions you’re going to receive in order to stay on track and keep your head above water. How you approach your shift can make or break your entire day.
Others Believe in You
Scared? It’s natural to be nervous on your first day, but, remember, your preceptor and manager have decided that you are ready to come off orientation, and they have a lot of experience evaluating job performance. You really ARE ready, they see it in you! And you are never alone, there is a whole team to help you.
The most important thing is to stay in control of your day. Time management is really self-management. You don’t manage time, you manage yourself.
Get to work early to start your day right, giving yourself time to read break room memos, pack your pockets, assess the vibe of the unit, go the bathroom (prophylactically! Last chance).
Take a deep breath. Mentally, tell yourself you will keep cool no matter what happens. Expect the unexpected interruptions, missing meds, infiltrated IVs, surprise information not included in report.
Make sure you have key phone numbers on your clipboard, so you don’t waste time later. Respiratory Therapy, number of supportive, encouraging nurse co-worker Lisa, Pharmacy, Lab. Are student nurses on today? They can do some procedures.
Your first priority is to lay eyes on each patient, even if you don’t do a full assessment. (If you do bedside report, you’re ahead of the game).
Right after report, start rounding. Do not pass Go, do not return to the nurses’ station to visit. Quickly, before the interruptions start.
Have a Plan
You already know you have to give FFPs, and have a complex dressing change in an isolation room- your plan is to give the FFPs after rounding, before lunch (patient is going to GI Lab at 1500), and the dressing change can wait till afternoon. You already have one discharge, all the more reason to get things done early. Good plan!
Let go of the Plan
The plan will change all day long, so be flexible.
Limit Your time in Each Room
Introduce yourself to your patients but don’t get bogged down. Say you’ll be back with meds and to do an assessment let them know about any planned tests, procedures. This will reassure them that you’re on top of it, and are coming back. Spend only a few minutes per patient (15 minutes tops if you’re also passing meds).
Here’s an example of prioritizing and deflecting interruptions.
Patient # 1: NPO for open heart surgery, chlorhexadine bath given. Check. No water at bedside. Check. Flip open the chart and check that pre-op checklist is complete, and consent signed. Saline lock site looks good. Do a full but quick assessment (focused: no chest pain, lungs clear, sinus rhythm, no edema, labs normal) on this patient because Pre-op could call for him at any time.
Be sensitive to see if he seems nervous, and if so, acknowledge. Explain wife is allowed in Pre-op, etc. Make sure he knows he’s going to ICU post-op. Tell him you’ll see him before he leaves. Mental note to ask your nursing assistant to update his belonging list. Remember to say please and thank you! Time: should take less than five minutes.
Patient # 2: Has dementia, going to GI Lab at 1500. Asleep, he was up late and confused last night, let him sleep in. Has a sitter, give him your phone number. Make note to check on who signs his blood and procedural consents. Doorway assessment: Breathing regularly, skin color normal, no GI bleed through night, H&H pending, but you note IV bag is very low.
Interruption deflected: Adjust the IV alarm and rate (slow it down), so it won’t beep until you get back. With morning meds and new IV bag. But keep rounding.
Patient# 3: Acute pancreatitis. Focused fast assessment: check for pain and nausea, she denies both. Note IV site infiltrated. Turn off the pump, d/c catheter,
Interruption deflected: but don’t restart IV right now. It’s a maintenance IV going at 125 cc/hr, so if she just takes an extra few sips of water, she’ll be good! The IV restart can wait until after rounding, at which time you’ll return with IV start supplies, and pass meds at same time. Actually, you’re not sure she still needs IV fluids, make note to check I&O, see how she does with breakfast, check labs, and recommend saline lock to provider. Or if stable, maybe discharge? Plan to pass this patient’s meds last.
Interruption deflected: Phone rings. It’s a family member wanting an update on Patient # 5. You tell them you haven’t seen her yet, but you got in report that her Mom had a good night after one pain medication, and “I’d like to gather all the information for you, Lynda, and I’ll call back by 1000 unless something changes.”
Patient # 4: CHF, diabetic. Call light on. Elderly female patient, max assist, wants up to bathroom to wash her dentures and comb her hair. Alert and oriented. Sit her up at side of bed, noting skin is normo-warm, dry to touch, excellent position now to listen to breath sounds (crackles in bases), note mild bilateral edema of lower extremities, look at her backside.
Put on her slippers, note heels are intact, while asking when was her last bowel movement and palpating pedal pulses. Palpate soft abdomen, listen to heart sounds. Remind her to call you before she eats today, so you can give her insulin. Assessment done. Make note to look more closely at her 24 hour I&O status to determine effectiveness of diuretic. Keep an eye on her 02 sats, and lungs.
Interruption deflected: You know the bathroom trip will take more than ten minutes, so call your nursing assistant. Otherwise, you will get so behind. You are appreciative, and will help your nursing assistant later when you’re able, but she cannot hang your 0800 antibiotics for you right now.
Interruption deflected: Lab calls with a critical low potassium on Patient # 4. Although critical, orders are for coverage are in place, and have been used for her before. So it’s an expected critical. No need to call provider. (follow your hospital’s policy). As you walk by the nurses’s station, ask Tele Monitor if she’s having any rhythm changes. Plan to give her meds first, including potassium.
Patient # 5: Post-op open heart. You can assess lung sounds, chest tube, pacing wires, rhythm, all pretty quickly. Make note to get him up walking today ! Foley in and draining, there’s an order to take it out, make a note to grab a syringe and remove it later when you pass meds. Expect chest tube to come out, anticipate provider will ask you the output amounts (last night and 24 hour totals).
I know the above examples are for a pretty easy morning, which may not be typical, but here are some tips to help you on all kinds of days:
- Per CMS, some meds must be given within a one hour window; others within a two hour window; still others within a four hour window. That helps your time management, right? Read What is the window for passing meds? When is it a med error? (Also read here my big medication error I was Suspended).
- Don’t let everything that presents itself become the most important thing or de-rail you. You’re in charge.
- Set your phone to vibrate by 1100- theoretically, at least, you should be done with med pass and assessments.
- If you are not charting as you go on the computer, write quick notes on breath sounds: clear, rales bilaterally, etc. You’ll forget. You probably won’t forget LOC and normals, no need to write skin normal to remind yourself to later document skin normal in the computer.
- If asked for help during a med pass, it’s OK to say no: “I’m in the middle of a medication pass, but I can help you as soon as I’m finished.”
- Pain meds are an exception. Stop and administer, but also give any other medications you can at the same time.
- If on day shift, duck into the break room and eat some protein with some fat before 0900. It will keep you going later when you miss lunch or don’t get it until 1530. Limit high-glycemic foods to keep your energy level even.
- Purpose to stay hydrated. Even if it means you’ll have to go to the bathroom more often.
- As the day progresses, don’t gravitate to the most comfortable tasks first. Keep prioritizing, based on (1) patient safety and (2) time-sensitive tasks.
- Force yourself to chart. Don’t leave it until the end of the shift.
What tips have you learned to pass on to others? Take a minute and let me know, I’d love to hear!
Until next time friend,