It took a month, but nursing students are starting to show up on the general surgery floor. One of the first questions I field is, “who do we see first?” It will come as no surprise, nurse life is vastly different from school life. This is why a plan of attack is so important for patient care and time management.
In nursing school I remember instructors spending an inordinate amount of time worrying about the ABC hierarchy. This ranks airway, breathing, and circulation in order of importance. This is a textbook mindset. As if the charge nurse is going to give us a patient that is going to wait for us with an airway obstruction, a patient who’s stopped breathing, and another patient who’s just coded (heart stops); all at the start of our shift! Who do we see first!?
First, the odds of this scenario happening at the beginning of our shift is almost nil. Second, one person can physically only be one place at a time. Third, if we walk into a room and a patient has coded, we aren’t leaving them (even if another one of our patients stops breathing, codes or chokes). We are calling a CODE and immediately starting chest compressions because as we learn in our Basic Life Support certification, we value circulation above airway and breathing in a code situation. Pass the NCLEX then join us in the real world.
Here’s what I tell nursing students, “It’s our job to recognize the patients at risk for adverse outcomes and address the risks prior to them becoming a problem.” To do this we need to be efficient with our time to allow for careful and thoughtful assessment of our patients. We need to develop a plan of attack when we start the shift. Here are some of the basic steps I take to determine, “who do we see first?”
- Bedside report
- Level of acuity
- Why are they here (diagnoses, co-morbidities, etc)?
- Are they in pain?
- Are they in respiratory distress?
- Are they nauseous?
- Are they a fresh post-op day one, or are they leaving today?
- (any other questions that pertain to their current situation)
- When are they due?
- Are they time sensitive (IV antibiotics, insulin, etc)?
- Do I need to bring in PRNs?
- Exams and procedures
- Do they have an early AM appointment like dialysis or colonoscopy?
Based on what I see in my bedside rounding, I mentally queue these patients. (Side note: I hate the term ‘multi-tasking.’ As nurses we need to have absolute focus on one action at a time, but always know where we are going next. Hence, “mental queuing.”) As soon as I get my initial impression of the patient I rank them. When I say hello, I quickly gather any pertinent info needed (pain/nausea/breathing) to determine if I need to bring in a PRN or call respiratory therapy for a nebulizer treatment with their first round of medication.
I have started a shift and observed a patient unresponsive during bedside rounding (that’s why we do it). This shouldn’t be the norm, and if it is, it’s probably in the ICU where the nurse to patient ratio is 1:2. All things considered equal (stable), the mental queue is constantly changing based on the information we gather through assessment or updates from MDs, Techs, etc. If someone becomes more acute than before, then get bumped up. If a patient is going to dialysis, they get bumped up because we might not see them for several hours. If a diabetic patient’s blood sugar is 121 and doesn’t require meal time coverage, they get bumped down, and so on.
I hope sharing this philosophy, or plan of attack as I like to call it, gives the reader some ideas on how they can efficiently approach their next shift. Please feel free to share your plan of attack in the comments.