Write your patient's medication/treatment schedule, code status, abnormal lab values and (very) brief social history somewhere on your assessment sheet. Write them in the same places every time. By social history, I mean like: “M 34 yrs old, married, daughter works nearby, smokes 1 ppd, catholic.” (Jerry Goure)
Some instructors strongly recommend you get an O2 sat ASAP on everyone, because anyone can "take a dive" quickly in a med-surg unit. (Jerry Goure)
"VSS" is great shorthand. Use it when you can, i.e. when the instructor allows it and vitals really are stable. (Jerry Goure)
Tell clients that using the incentive spirometer will help prevent pneumonia and will help get them out of the hospital as fast as possible. This seems to make them more compliant. (Jerry Goure)
Know the normal ranges for vital signs in your patient population. (Fely Tran)
SCVMC Tips
IV tubes are often reused, but the Luor-Lock adapter is generally changed each time you hang a new bag. Fresh adapters can be found in a drawer in the med cart. (Jerry Goure)
When you will hang an IV med, try to look for the bag at least 30 minutes prior to the time on the MAR. One day my patient's med couldn't be located and my nurse and I had to call the pharmacy to order it. I suppose this goes for PO medications too. (Jerry Goure)
Fill out the graphic right after your AM assessment. Chances are the VS will be needed by someone. (Jerry Goure)
With two patients, never leave charting for later. Not finishing block charting is bad, not finishing the VMC paperwork is fatal. (Jerry Goure)
Every time you enter data into the patient's graphic or flow sheet, skim the entire document for errors or omissions Compare your data with the night shift's data, but don't be afraid to fill out more than the night shift. (Jerry Goure)
Have a classmate carefully read over the entire graphic and flow sheet for errors and omissions. Do this when you add up your I&O at the end of your shift. (Jerry Goure)
O’Connor Tips
Check the main IV to be sure it's connected and running BEFORE you need to give an IVPB. If the main line is not running, ask someone to start it for you, because it could take a while to get it going. (Dan Weisberg)
Pull ALL the medications (PO, IV, injections) you'll be giving on your entire shift and put them in the med cart. That way you'll be ready for the instructor at any time. (Dan Weisberg)
Medication allergies are incomplete and scattered! Find allergies on MAR, Kardex, charts (search), and wristbands. Don't be surprised if you get differing information from each source. Also, I found lots (more than half my patients) receiving meds (or from the same class) they were supposed to be allergic to. (Payton Wong)
Listen to the phone reports before your nurse deletes it. Often while reading MARs, Kardex, Charts etc., you'll hear the night nurse give her phone report. As soon as the report is finished, retrieve it! But remember not to delete. (Payton Wong)
