Last night was probably one of the more brutal nights in preparing for school. Had to go to the St. Cloud Hospital and find my assignment for the next morning. That part was easy, so was introducing myself to the patient I would be taking care of the next morning (along with the primary RN). Then came the intensive "homework" on my patient. Assignment: go through every part of their medical record, finding past history, current issues related to admission, lab values (knowing what is within normal values and what is not), vital signs, eating habits, family, and then the "list of all the medications" they are currently on, including any nonprescription OTC medications they may be taking. Then find all the interactions, nursing diagnosis, side effects, pharmacokinetics on the med, drug/drug interactions..... and the list goes on. We were able to purchase "premade" drug cards which is all well and good until the patient is on a medication that is not in the "box"... then you make your own! Lots of work there.
Once you have all the information you can possibly extract from their medical record, you need to develop a care plan, which includes: nursing diagnosis, desired outcomes, goals to help patient achieve this outcome, nursing implementations to help achieve this goal....etc. Thank goodness we only have to do this times total, and only for one patient each week. I think next time will be easier because I will know what to do and things won't be so "scary" and new.
Today we "worked" at the hospital. One on one with a single patient. Being responsible for head to toe assessments, vital signs, charting, and personal cares: loved it!! That was a welcome change from what I was used to working at the nursing home. (12+ residents for cares, and/or 26 on a wing for medications) A whole new appreciation for the work that the nurses do that is not so visible. It is not just "passing pills" and giving IVs, etc. I knew all this ahead of time. I had participated for a number of years in care plan development when working at the nursing home. My patient today was elderly...I really love working with that generation. I want to specialize in geriatric population. But my first goal is to graduate with my BSN (4 year RN degree). May 2013 here I come!!
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