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Shhhhhhh…..
I don’t normally share the deepest secrets of my trade with just anybody.
But you? you are special!
Pull up a chair and listen closely….. I will reveal to you a mystery of life which will change your destiny….. if you can handle it….. after this your nursing school trajectory will be brighter and happier….. and while you are at it, subscribe to this blog and share it with your closest friends.
Oh, and buy my book.
Skills are more than psychomotor by nature
Okay, so I teach beginner nurses how to be a nurse. We start with well-meaning intelligent kids and turn them into professional persons. When people think about the skills nurses need to have, they list things such as giving a shot or doing a dressing change. Using sterile technique and doing the Five Rights of medication administration. Close your eyes and picture a nurse at work, and this is the image that comes to mind. These are the psychomotor skills, hands-on things we do for people.
It’s just as important to learn how to juggle time, set priorities and estimate workload, but these are “soft skills” – and a behavioral scientist might argue that since these can’t be demonstrated, they do not exist….. now – an educational paradox exists.
The Road Map to Success
The key to learning these skills is to learn how to use a Nurse’s Brain, what I also call a road map, and to incorporate it into your daily life. If you are not now doing this, it will be the biggest single revelation of your trip through nursing school.
Simplest version of instructions
This is part of teaching a new nurse how to prepare. Depending on your curriculum, the faculty will tell you ” go to the hospital the day before and learn about your patient.” A less experienced faculty member might leave it at that, and set you loose. Nobody tells you how much is “enough,” but a less experienced faculty will reserve the right to criticize you when you didn’t do it right.
Long ago I learned that beginners need to be shown how to prepare and given a specific description of what this entails. Effective prep is a skill in and of itself. Here goes.
Here is how to prepare
You will read the chart for all kinds of things – the diagnosis, allergies, meds, etc. your school will give you a template as to things you are looking for. look up each med the person is receiving. that sort of thing.
BUT, in addition to this – when you read the chart, you find the specific list of interventions and activities for the day. they will be always be somewhere, in the old days it would be found in the “Kardex”.
Six Steps to actualize it into reality and answer the question “what do nurses do all day?”
1) Start with the orders. A typical list goes like this:
allergies: none known
diet: NPO
v.s. q 4 h
activity OOB to chair TID
midline w > d dressing to abdominal wound q 8 h
I & O
foley catheter to bedside drainage
veno-dyne boots to LEs while in bed
pain med PRN
IV D 5 NS at 125/hr
That sort of thing. okay, this was simple enough. your job is to make it happen.
2) The next step is to assign a specific time to each activity. so you make a piece of paper that looks like this:
0700
0730
0800
0830
0900
0930
10 00
1030
1100
1130
You can make a template for this, and there are lots of examples of sample Brains out there….
3) next, take all the items on the first list, and add them to the second:
0700 – nurses report, find out who the nurse is.
0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter
0800 – mouth care ( since he is NPO),
0830
0900 – ask about pain med again,
0930 -dressing change
10 00 – get OOB to chair, check I & O,
1030
1100
1130 – take vital signs again (it’s four hours since the ones you took this morning)
4) next, go through the list again, and add stuff that is assumed to be needed, according to the routine of the unit
0700 – attend nurses report, find name of staff nurse also covering your patient
0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter
0800 -look at IV site q 1 h
0830 – bathe patient
0900 – ask about pain med again, -look at IV site q 1 h, give 0900 meds if any
0930 -dressing change, ask about pain if the patient got some med in advance
10 00 – get OOB to chair, check I & O, -look at IV site q 1 h
1030
1100 – write DAR note in patient chart, complete ADL checklist
1130 – take vital signs again (it’s four hours since the ones you took this morning), report off to staff nurse
5) next, add some details that might not be obvious. put a box next to each item so that you can check it off when it is done.
0700 – attend nurses report ___, find name of staff nurse also covering your patient ___________ read specific instructions for dressing change and check to see if supplies are in the room _____________
0730 - take vital signs, ______________and report to staff nurse,____________ ask about pain,______________ assess dressing, _____________check venodyne boots _________________ and IV site, ______________look at catheter, ______________check sacrum and heels,____________ reposition if needed,___________ listen to Bowel sounds____________ and lungs______________. confirm that ID band is in place________________ (so you will save time later when giving meds). check call bell and make sure patient knows where it is ___________
0800 -look at IV site q 1 h ______ assess mouth and do oral care ________________ see if any other students need help with turning their patient or incontinence care _____________ doctor’s rounds _____________
0830 – bathe patient ______,do cath care ___________ complete head-to-toe assessment sheet from School for care plan.___________ ask patient about discharge plan, _______________assess need for teaching _____________ leave bed in low position after bath __________
0845 - short coffee break _________ report to nurse that you will be leaving for fifteen minutes ______________ check to see doctor’s orders if any new ones weree written ___________ check lab results for today _______________
0900 - ask about pain med again, _________________-look at IV site q 1 h, _____________give 0900 meds if any. ____________make sure you took B/P _________before giving meds. ____________decide what the theme of the DAR note will be. _________________
0930 -dressing change,____________ (follow recipe) ask about pain if the patient got some med in advance,
10 00 - get OOB to chair,_______________ check I & O,_____________ -look at IV site q 1 h_____________
1030 -
1100 – write DAR note in patient chart___________, complete ADL checklist ___________
1130 – take vital signs again (it’s four hours since the ones you took this morning), ____________________ report off to staff nurse _________________
This is the short version. When I first teach people to do this, they may have up to forty items on the list, because they need reminders of everything. As you can see, the Brain evolves as you add things to it. doing a dressing is more than just doing the dressing – it’s checking the pain med, checking the order, gathering supplies, and negotiating a time. each of these gets their own spot on the checklist.
If your whole clinical group is using something like this, you can plan your work as a team; you can make time to help others; and you learn to share a language as to when each team member needs help or not.
6) During the time at clinical:
The Nurses Brain goes on a clipboard, and you refer to it every fifteen minutes. cross off each item as you do it. at 0900, every item that was assigned a time before 0855 ought to be done. If not, you now know which are the priority items. when something happens during the day, such as a med not in the drawer when you go to get it, you make a note to yourself using this sheet, to recheck later. assign a specific time to every event. which specific time doesn’t matter as long as there is one!
Florence Nightingale herself once said that for a nurse, learning to use pencil and paper was far more important than learning to use a stethoscope. Okay well, we’ll teach you the stethoscope too, but this Brain is what the pencil and paper are for!
There is an old rule that if you get your stuff done, and become known as a person who always completes their tasks, you will be rewarded by being assigned more tasks the next time. You can not possibly achieve this state of bliss unless you use a checklist.
Using your brain is a key to college – using the Nurses Brain is the key to successful nursing!
Tomorrow: Part Two: checklist culture and your role in quality. There is a lot of attention being paid to this issue, and if you are the kind of nurse who makes “to-do” lists, you will succeed in nursing and in life.
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Joe Niemczura has been an RN for 32 years, split evenly between adult critical care and teaching. He is the author of the book “The Hospital at the End of the World.”
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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