Nursing Playbook

Nurses are the frontline. You are the front line or the Viola section of an orchestra.

Playing football and music
Nurses are the front line and the heart of the orchestra

You are the team’s primary link to the patient. You do the heavy lifting. Without you there is no care!

  • Give medications by mouth and intravenously
  • Document input and output and monitor vital signs
  • Assure proper meals and nutrition
  • Constantly communicate with the patient and family
  • Provide your insights into the patients mental and physical well being to the entire team
  • MUST BE CLOSELY LINKED TO THE OTHER TEAM MEMBERS and participate on physician work rounds.
  • Remember you and the patients are the physicians’ customers and the physicians must supply clear and timely orders. If you don’t understand the treatment plan you must ask questions on rounds.

Remember you are the front line. You are the patients’ primary advocate and you have the most knowledge about the patient because you are at the bedside 8-12 h per day. Just as each football player needs to learn the basic passing motion, blocking technique, and the proper way to recover a fumble, or the basketball player needs to learn the proper shooting and passing techniques, you must learn and reinforce the fundamentals.

  • Succinct and efficient presentations: You need to speak confidently and efficiently. No mumbling and no standing behind the circle. Follow the communication protocol exactly. Remember efficient communication is a key fundamental.
  • Active involvement. You are accustomed to being ignored during work rounds, and are often hesitant to participate. You will be encouraged to participate. If you contribute to and understand the management plans, care will be more efficient and less error prone. Also the number of times you will need to page the house staff will decrease.
  • Nursing Work Rounds Protocol (~2 minutes) Use the SBAR and TEMP communication protocols. When possible present at the patient’s bedside immediately following interns presentation.
  • Discuss any patient events that occurred overnight  (use the SBAR format, see below)
  • Use the mnemonic TEMP to review key patient orders related to bedside nursing:
    • T – tubes IV lines, bladder catheter (are they needed, should they be changed
    • – Eating, exercise (activity, bed to chair, ambulating with assistance, need for PT), sleep and bowel movements
    • M – monitoring frequency  Vital signs Q4H or Q8H, when possible avoid during sleeping hours. Do the patient need telemetry? Does she require daily blood drawing?
    • P – Is the patients pain controlled? And finally does the patient understand the plan for the day? (teach back)

All questions by the nurse should be answered during rounds (eliminates the need to page)

How should you report an unexpected event? Use SBAR (very brief and efficient)

  • Situation: What complication has occurred. Example: Mr. Jone’s developed chest pain overnight that was left substernal, sharp and radiated down his left arm.
  • Background: Describe underlying conditions, his original reason for hospitalization. Example: Mr. Jones was hospitalized for hyperglycemia and mild diabetic ketoacidosis. he has received 10 Liters of fluid over 24h.
  • Assessment: What do you think is going on. Example: Mr. Jones may have received excessive fluids. On exam I hear rales half way up both posterior lung fields, his heart rate is elevated at 120 and he has jugular venous distension. I suspect his chest pain is due to cardiac ischemia resulting from increased cardiac work because of CHF.
  • Recommendations:  What do you think should be done? Example: Should I order an EKG and ask the technician to draw cardiac enzymes? Do you want me to give him lasix? How about heparinizing him? We have been told that all patients with possible MI should also receive asparin and a beta-blocker. Do you want to order these?

Physicians Work Rounds Protocol (Duration < 5 min)
The intern will present the progress of the patient, and this should be short enough to give you time to provide your input. If you have a different understanding of the patient’s complaints feel free to make additions to the interns presentation.
Subjective complaints:
–    List Positive ROS
–    Emphasize complaints relevant to the current problems

Objective findings:
–    Vital Signs
–    Positive physical findings
o    Focus on findings related to the patients active complaints
o    What findings were positive on admission (be sure to include these)
–    Abnormal laboratory findings
o    Usually include CBC, Electrolytes.
o    Results of new diagnostic tests

For Each Active Problem Give:

–   Impressions
o    When appropriate give your differential diagnosis
o    Is this problem improving, worsening, or staying the same?
–    Plans
o    Diagnostic

  • List blood tests
  • Radiology tests
  • Other tests

o    Treatment

  • What medications are you administering for this problem
  • What other modalities are you instituting

Today’s to do list
Potential Discharge Issues