Meal Planning Tips and Tricks for Nurses – Part I

Meal Planning Tips and Tricks for Nurses – Part I

Learning how to get my meals together was a challenge when I was adjusting to working three 12-hour shifts per week. I always waited until I was hungry, never had the food in the house to make something yummy and quick, and then would either go to the grocery store last minute and spend way too much or eat out and make poor decisions out of hunger.

If you plan your meals, you will ultimately spend less money and waste less food. You also may potentially eat healthier, depending on your meal choices.

This will be a two-part post. This post will contain my keys to success in meal planning and the next post will have our typical weekly routine and the meals (with recipes!) that we make.


Please note: my household consists of my husband and I. We do not have children. I know that can add a big challenge into your planning and time management. We also try to eat low-carb and natural, but aren’t super strict about it. When deciding on meals that are right for you, adjust suggestions for your diet (dairy-free, gluten-free, vegan, vegetarian, etc.) as appropriate.  

Additionally, this is what works for our household. Please don’t read this and assume this is how I believe all households should function. This is what works for us.

 Please keep all of this in mind when reading my routine.


Keys to Meal Planning Success

Communicate with your spouse / partner / roommate about expectations

My husband and I have an understanding – we try to split up who makes dinner evenly throughout the week. We both work full time, so we both spend the same amount of time with work and other commitments, therefore we try to make time and spread the responsibility of dinner equally. I know this isn’t how everyone’s household functions, but this works well for us, and ensures that neither feels overwhelmed or like the other does not help.

Sit down and plan the week together

Take some time at the beginning of your week to plan a dinner for each night. It is annoying to do this, but it’s much less annoying doing it once rather than every night of the week. Base your grocery store shopping list based off of your meals.

For the days you’re working 12-hour shifts, stick to meals that are easy to prepare and require minimal prep.  I save the easiest meals for my three days I’m working (or the ones John is most comfortable making, as he typically makes dinner on the days that I work 12’s).  I like to try new recipes, so I save those for days I don’t have a lot going on.  We look at our calendars together while we’re planning our meals and if we have a lot going on one day, we make it an easy meal or one we can prep for earlier in the day (like a crock pot meal).

I write down each day of the week, what we’re eating, and who is preparing it and stick it on the fridge to reference later in the week. It is very easy to forget.

It makes a big difference when you’re getting off of work and you already know whose responsibility it is to make dinner and what it will be.

Also, John and I have an understanding that if I make dinner, he does the dishes and vice versa. Outlining those expectations and communicating about them clearly is essential to avoid undue conflict and stress. It is pretty burdensome to work a 12-hour shift, make a full dinner, and clean it up.

Get some really good food storage containers that you can bring to work for your lunch

I like to bring leftovers for lunch at work the next day. It makes cleaning up the meal and packing my lunch easier. I prefer glass containers over plastic. Here’s why.

It’s also important to have an organized container drawer. We separate our lids and containers to make finding a match easier. I also recycle any that don’t have a matching lid to de-clutter where I store them. Spending more than 10 seconds trying to find a container and a lid is way too long in my book!

Oh, and don’t forget to have an awesome lunch box!

Buy meat in bulk and freeze it / Prep ahead of time

We buy meat from Costco (enough for about 2 weeks at a time), separate it into single-meal Ziplocks and freeze it. When I see that tomorrow ground beef is the protein for the meal, I move the frozen meat package from the freezer to the fridge the day/night before to allow it time to defrost. I hate thawing meat out last minute and it takes that annoying step out of the equation. 

If you have a meal that requires chopping veggies that can be a little labor intensive and have time the night before or earlier in the day, do it then and throw it in the fridge so you can just throw ingredients together come dinner time.

Have a quick back-up plan in the freezer

We all know it happens – someone codes at shift change, you get off work an hour late, and your spouse had a terrible day as well and walks in the door 3 seconds after you. I like to have a frozen pizza or some sort of frozen meal on deck for those rough days.

Get on Pinterest

Pinterest is where I find almost all of my recipes.  I have a board called “Noms” that I reference frequently and utilize my iPad or computer to look at the recipe while making dinner if I don’t know if off the top of my head.  It’s incredibility convenient and easy to organize.  You have all of your faves in one place that is easy to get to.  I highly recommend Pinterst to aid in your meal planning!

Say thank you

If your husband, wife, partner, roommate, etc. made dinner tonight, tell them thank you. If you made dinner and they washed the dishes, say thank you. If you live alone and you are super pumped that you remembered to defrost the meat every day and stuck to your list and you’re pretty proud of yourself – give yourself a pat on the back! Everyone loves to be appreciated and have their actions acknowledged, even if it’s routine.

Those are my meal planning keys to success! Is it realistic to do things the best way every single time? No. John and I have planned out our week and had to change things up mid-week because circumstances that we couldn’t predict forced us to do so. But we make an effort to stick to the plan, and we’ve quickly learned that having a dinner plan for the week is much easier and cheaper than not having a plan at all. And now we don’t stress as much about an impromptu take-out meal after a tough day because we’ve become more efficient overall with our planning and spending.

I hope this helps! Stay tuned for Part II, which will contain a sample week of meals, and I will walk through our routine and provide the recipes to our go-to meals!

Are you a meal-planner?  What’s your routine?  What tips and tricks do you have?


Nursing Time Management for When You’re Totally Overwhelmed

Nursing Time Management for When You’re Totally Overwhelmed

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time management

It never fails. You start your day with the best nursing time management intentions.  You started your assessments and meds on time (woo hoo!), and then all of a sudden three doctors round at once and expect you to implement their orders immediately. One patient needs to pee, one needs pain meds, lab is on the phone with an alert lab value, a family member is on the phone waiting for an update, and the STAT med you called for an hour ago hasn’t shown up yet.

Good. Lord. What do you do now?

While this may seem extreme, it’s kind of not because all day you will be prioritizing and re-prioritizing. When you think you have your next two hours figured out, something inevitably comes up. The key is being able to re-prioritize in an instant.  Learning nursing time management is essential to being a successful nurse.

I will tell you what I do when I find myself suddenly so overwhelmed that I don’t even know what to do next…

Learning nursing time management is a process

You may want to be perfect right away, but that is an unrealistic expectation.  Stephan Curray didn’t become a lights-out point guard overnight, Harry Potter didn’t learn a Patronous charm in one session with Lupin, and Adele didn’t learn how to sing like an friggin angel with her first note.  You will do things inefficiently.  You will learn some things quickly, and some will require multiple explanations and attempts to sink in. You’ll think you have something figured out, then a new doctor comes on the scene and changes things up… please, have patience with yourself and don’t beat yourself up when it takes time to become efficient. Remember, you’re not only learning what to do, you’re also learning how, where, and when.

Stop and take a deep breath

Calm yourself down first and get in control. Don’t just go run and complete whatever task is fastest first… you need a plan to maximize your time.

The first pulse you take is your own.

Think about which patient is the LEAST stable and address them first

Please keep in mind; this is not always the one complaining the loudest. While one patient may be extremely upset that it’s taken 45 minutes to get them their 4 mg IV morphine, your other patient who just had a graft placed with a blood pressure of 192/91 is your priority.

What can you delegate?

If a patient needs to pee and a CNA is available – delegate. If a patient needs pain medication and you know another nurse is caught up, ask if they can give the med for you. Nursing is a TEAM sport. We all are taking care of the entire unit together. That means when you’re caught up, you’re helping others who are behind. Trying to do everything on your own when others are caught up is a disservice to yourself and your patients. You will be running ragged and your patients’ needs will take forever to get addressed. Working together as a team is an essential part of a well-functioning and safe nursing unit.  I know it can be hard to ask others to help you, but please do.  Most are more than willing to help.

What can you do simultaneously?

If a family member is on the phone wanting an update but you also need to see what meds you can give another patient, look that up while you’re on the phone.   Whenever I’m on the phone and anticipating being on hold, I always get by a computer and chart or look things up simultaneously. Consolidating tasks, trips, phone calls, etc. is essential. When you see a patient, always ask if there’s anything else they need before you leave. It’s incredibility inefficient to be with a patient and try to leave immediately without asking if they need anything first, because they will inevitably put on their call light 7 minutes later for something you could have addressed while you were in the room.

Remember that charting is now the last priority

If you do have a second, chart the random/difficult to remember thing, but this matters the least right now. Always chart your medications in real-time, but charting assessments can wait when you’re that far behind. Make notes if you need to, but if you’re running from an unstable patient to a new admit to a screaming discharge, charting is going to wait.

Apologize for being late with things to patients and families

Never respond with excuses – they don’t help the situation (and honestly they can make it worse). Sincerely provide a heart-felt apology even if it was not your fault. Knowing that you are truly sorry for taking so long to get their pain medication (even though you were hanging blood, rounding with an upset physician, and giving an antihypertensive med for a patient with an BP of 238/104) really means a lot to people. Additionally, apologizing immediately can smooth things over before they get rough. Having a grumpy patient or family can make the shift pretty tough.

  • Example of what not to say: “Sorry it’s taken so long for me to get here. We’re so short staffed today it’s not even funny!”
    • Why this is no bueno: Techincally you’re apologizing, but you’re also telling them there’s not enough staff there to quickly address call lights. While that may be true, it will make your patient and their family uneasy and nervous, which won’t help your situation…it will only make it worse.
  • Example of what to say: “I’m really sorry it took a while for me to get your medication. How have you been feeling? Is there anything I can get for you while I’m here?”
    • Why this is better: You apologize and acknowledge their concern/frustration immediately and quickly center everything on how they are feeling and their needs.

I know it’s really frustrating to be short-staffed and drowning all day. I’ve definitely been there and it’s pretty overwhelming, even for experienced nurses. However, it’s not the patient’s fault that 3 nurses called out and we couldn’t get the CNA’s we need, so just apologizing to them is the best approach. That frustration and need should be directed towards management, staffing, or whoever would be appropriate in your facility – not the patient, even if they’re really upset.

Remember: it’s a process

Even though I’ve been a nurse for seven years, I still have to remind myself of the above things. Sometimes I get overwhelmed and can’t figure out what to do next and have to remind myself to stop and go through the steps. Occasionally, I have to talk to a coworker… “Ok, I’m really overwhelmed and I’m not sure what to do next right now?” …just talking through it out loud to someone else helps me focus and figure out my priorities.

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Delegation Tips for Nurses

Delegation Tips for Nurses

Delegation Tips for Nurses

Delegation is a tough thing to master as a new nurse.  While the NCLEXNCLEX tells you which tasks are appropriate to delegate, it doesn’t exactly outline how to go about doing it.

I realize that not all units have certified nursing assistants (CNAs) or patient care technicians (techs), but many do.  This post is for those of you that are faced with this particular challenge.

While you may have mastered it on the unit that you work on, if you transfer to another hospital or even a different unit within your same facility, it’s like you’re starting all over again.

I think delegation is tough because you’re a new person walking onto a unit, becoming part of a team, but you have to delegate various tasks to people that have been on the unit for years.  Some have been informal leaders on the unit for decades.  And let’s be honest, it can be tough to be told what to do by people you just met.  You don’t trust them yet, you don’t know them, you don’t know if they’re good at their job.  While that doesn’t excuse not doing what you should, I get it.

Here are some tips for molding yourself into the team quicker, which will, therefore, make delegation easier.

During orientation, observe how your preceptor interacts with your CNAs

How do they respond when they’re delegated to?  Do they function well as a team, or do people work independently of one another in their silos of patients and let each other drown?

Observe from afar how things function.

If they respond well to them but later are not so great to you, you know you need to work at your relationship with them, and they may feel you need to prove yourself.  Also, see how your preceptor goes about delegating.  Are they good at it? Are they respectful and nice or do they act like the CNAs are their minions?  Typically, preceptors are informal leaders within the unit and if the leader of the unit is mean to the CNAs, that behavior may continue to the rest of the nursing staff, which fosters a pretty tough work environment for everyone.  You want to build a good relationship with your CNAs!

If you have a good and trusting relationship with your CNA’s, you will motivate them to give your patients phenomenal care. People want to do a good job for leaders they respect.  If you’re a nurse – you’re a leader, whether you like it or not.  You are the leader of your patient’s care team, and that includes your CNAs.

During orientation, work on building your relationship with them before you’re responsible for delegating

Get to know them (ask them where they’re from, how long they’ve worked there, if they’re in school, etc.).  I don’t know about you, but when I’m at work and someone that is responsible for telling me what to do (like physicians, PA’s, NP’s, managers, assistant managers, etc.) takes the time to get to know me, I feel valued.  I also like to try to get some inside joke going.  Example: when I started at my current unit I figured out that one of the CNAs liked Kevin Hart stand-up.  So I randomly quoted that, or when I asked her a question and she answered, I’d say “alright alright alriiiiggghhht!” in true Kevin Hart fashion.  I may have yelled it a little loud it the unit, but whatevs.  It got her laughing and facilitated the development of a relationship.

When you’re starting to be on your own, even during orientation, touch base with them first thing in the morning (or night!)

After you get the report and learn about your patients, touch base with them.  Let them know your game plan for the day (who needs baths, who is traveling off the unit, who may discharge/transfer, who is a high fall risk).  Even if they’re not responsive to this – do it.  It establishes a routine and facilities communication and teamwork.  And if they complain about it, make a joke out of it.  “Humor me and let’s huddle for a sec! You know you love me!”

It’ll lighten the mood and make them more likely to jump on board.  Then they know that whenever you’re working, you’ll track them down to touch base with them.  They’ll expect it from you and it will become routine.  While people may fight it at first, it’s better for patient care and teamwork in the long run. When the nursing unit functions as a team, the patients get better care, the staff is more satisfied, and everyone wins.

Understand where they’re coming from and their priorities

Remember when you were first becoming a nurse?  Remember when things started to get hectic and you had trouble learning how to prioritize?  Remember when all you wanted to do was the easiest things first, even if they weren’t actually the priority?

The natural human response when it gets really chaotic and you have many tasks that you need to complete is to do the things that you’re most familiar and comfortable with first.  When you’re growing as a nurse, you’re learning how to see past that natural urge and do what the patient needs first.  CNA orientation isn’t long or detailed enough to touch on that, so when you see that happening and you need to redirect them, be sure to explain the reasoning.  “Hey, Mr. Smith in room 6 isn’t doing so hot right now.  I know you have your rounds to do, but I need a full set of vitals on him STAT so that I can let the doc know about everything that’s going on.  I’ll look up labs/meds.”  (Also, that kind of phrasing is a subtle way of addressing the problem as a team.)

When they’re doing something incorrectly, nicely explain the correct way

For example, if they’re measuring urine output incorrectly from the foley catheter – take 5 minutes to nicely educate them.  Foster an environment and relationship where they feel comfortable being honest with you when they don’t understand something or need further clarification.  What does that look like?  Don’t react like they’re stupid if they don’t understand something obvious to you, don’t go talk to other nurses and CNAs about how you can’t believe they didn’t know something, and don’t just take care of it yourself without talking to them and then get upset that you have extra work.  Educate them, be honest with them, be nice to and understanding with them.  I know when I was learning things in the hospital, sometimes it took a few times of someone explaining something for it to click.  Be patient and kind.

Most people just want to do the right thing and make errors because they honestly don’t know.  I’ve heard so many CNA’s say, “I didn’t know I was doing something incorrectly and then I overheard them talking about how I’m doing something wrong.  I wish they would have just told me or taken the 3 minutes to show me the right way to do it.  And now they’re complaining that they have all this stuff to do that’s my responsibility but I’m scared to ask them how to do it right because they’re just going to be a jerk to me.”    Seriously, I’ve heard that so many times.

How it can feel when the nurses all talk about you when you didn’t know you were doing something wrong..

Say thank you

I sincerely appreciate a good CNA. My day is 900x better when I’m working with a  CNA who is a team player, understands prioritization, and is making an effort to be efficient.  Therefore, whenever I see people doing a good job, I say thanks and show some appreciation.  I think about how I feel when a manager, assistant manager, physician, or NP/PA tells me I did a good job, and I want to extend that same courtesy to them.

Dear proactive and awesome CNAs, LOVE YOU.

Be considerate and work together

We all know call bells come in waves.  So when 4 call lights go off and 4 of your CNA’s 8 patients need to go the bathroom simultaneously, help them out. Talk to each other and attack things as a team. I know we have a ton of things to chart and take care of, but leaving them hanging like that just isn’t cool.  I know we need to chart (and have a lot to chart!), but expecting one person to take 4 people to the bathroom simultaneously just is not realistic.  The name of the game is working with the least amount of staff on nursing units as possible, and if we don’t work together as a team to tackle call lights and patient needs, we’re all going to drown.

GO, TEAM!  You can be Will Smith. I’ll be Bear Hat.

It’s also important not to think there is a task that only CNAs can do.  Under your nursing license, you can do whatever they can do.  However, it’s not always the most efficient for you to do those things.  But, if you spend 15 minutes finding a CNA to do something you could have just quickly done yourself, that’s just as inefficient, if not more.  It’s also pretty inconsiderate.

Here is the common CNA / nurse unwritten rule:  if you, as a nurse or CNA, are charting or at the desk not doing anything in particular, and one of your patients needs something – you are expected to address it.  If you are at the desk, catching up on charting and a coworker’s patient needs something and they are busy with another patient – you need to address it.  The expectation is that they will do the same for you.  That’s how well-functioning teams work.  Not everything will always be equal, but patients will be safe and their needs will be addressed.

Charting is always something that can wait if a patient or family needs something.  When I was a CNA, I had no clue how much nurses had to chart until I actually did it.  If someone needed something and I still hadn’t charted my rounds, too bad… they had to wait. Now I realize how wrong that was because the nurses were much farther behind than I was but they sucked it up and took the patient to the bathroom.  And I got out on time, if not early, and they stayed late to chart.  Sometimes they stayed hours late charting.  Looking back, I see how inconsiderate that was and how that may have contributed to a rocky RN-CNA relationship.

If you are not a nurse, please read this post where I wrote out all of the things nurses are responsible for charting on each patient.  It’s beyond excessive and millimeters away from unrealistic.  And I even forgot some things and people added it in the comments!

So, that’s my delegation orientation in a few hundred words and 7 GIF’s.  Does your unit work well as a team?  How do you go about delegating?  What did that process look like for you at the beginning, and how does it look when you get new CNAs?  And if you’re a CNA, what do you wish the nurses delegating to you knew?

Want to hear more about delegation and other tips and tricks to help you ease into your practice as a new nurse?  I wrote an entire BOOK full of advice!

Click the image below and it will take you directly to Amazon to purchase it!

Becoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and YourselfBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and YourselfBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and Yourself

More resources on Delegation Tips for Nurses:

New Nurse's Survival GuideNew Nurse’s Survival GuideNew Nurse's Survival GuidePearson Reviews & Rationales: Comprehensive Review for NCLEX-RN (2nd Edition) (Hogan, Pearson Reviews & Rationales Series)Pearson Reviews & Rationales: Comprehensive Review for NCLEX-RN (2nd Edition) (Hogan, Pearson Reviews & Rationales Series)Pearson Reviews & Rationales: Comprehensive Review for NCLEX-RN (2nd Edition) (Hogan, Pearson Reviews & Rationales Series)20 top tips for Delegation20 top tips for Delegation20 top tips for Delegation


Navigate Your First Nursing Conference Like a Pro

Navigate Your First Nursing Conference Like a Pro


In my mere 5 years as a nurse, I’ve been to 6 national nursing conferences (NTI, Magnet, AONE, and the National Nursing Symposium). And I love them. You get to learn about what some of the most successful people across the country are doing in their units, you get invigorated and inspired, and you begin to understand what our profession as a whole is going through.

I’ve developed some of my do’s and don’ts of nursing conferences, in hopes that it will help you navigate your first conference like a pro!

Do plan ahead for your concurrent sessions

Many times there are large group sessions and break out sessions (also called concurrent sessions), and you get to choose which ones you want to attend. If they have the schedule online beforehand, plan your day before arriving. Otherwise, you’ll be scrambling to figure out which ones you want to go, which can be a headache last minute. You may miss awesome sessions if you don’t manage your time well.  Additionally, have a back up session nearby in mind, for reasons I’ll discuss later.

Don’t wear uncomfortable shoes

Nursing conferences mean lots of walking. Seriously.  So much walking.  Wear business casual attire, not scrubs, and try to find some comfortable appropriate shoes. Wearing the wrong shoes can make you absolutely miserable, so put in some time when considering your shoe selection!

Tieks are my favorite conference shoes.  They are expensive, but so worth it to me.  I wear mine for all business casual events.  I can walk for miles in them and still look fly.

Do be selective about what you take from exhibitors and who scans your badge

While at the conference you’re required to wear a badge, which has a barcode on it. A lot of exhibitors sponsor giveaways, and the way you enter is by letting them scan your badge. That gives them your contact info if you happen to win. While that’s great, they also have your contact info to now email you and mail you things. Ugh.

The same applies to freebies (pens, water bottles, more pens..). All of the exhibitors typically have something small with their logo on it to giveaway. I always am selective about what I take with me because it’s another thing to carry around and/or dispose of. Unless I plan on purchasing an item or want to learn more about the company or school, I decline when they want to give me information.

Do bring your own bag that you’re comfortable carrying the entire time

You’ll get some freebies, potentially purchase things from the bookstore, and will need to carry around various papers and things that you’ll need during the day. They typically give you a bag when you register upon arrival, but it’s nothing like a real over-the-shoulder bag from home. Bring a good, lightweight bag that you’re comfortable carrying around literally all day.

Don’t forget to stock your bag!

Things I recommend to keep in your bag include; a water bottle, hand sanitizer, a pen, quick snacks, a phone charger, a bit of cash, something take notes on, a map of the convention center/local area, gum, and a folder for papers.

Do pay attention to the social media scene

You really get a much bigger picture of the conference when you are plugged in on social media. I find Twitter to have the best participation and engagement. All conferences have a conference hashtag, For example, when I went to NTI next month in San Diego, I already knew the hashtag was #NTI2015. People tweet quotes, insider info, pictures, and even about giveaways on social media. Therefore, when you go to the respective social media outlet, you can search the hashtag and get plugged in immediately.  Twitter and Instagram are wonderful resources for conferences.

Don’t stay in the concurrent session if it’s not what you thought it would be

I plan my sessions before I get to the conference, and a few times I’ve gone to sessions that I thought were going to be about something totally different when I read the title. If within the first 5 minutes you realize this is not going to be helpful to you and your career, quickly go to a different session. These conferences are way too valuable to waste 1-2 hours in a session that’s not going to benefit you. This is why I have a nearby backup session in mind. This is also helpful if you get to your selected session and it’s full.

Do network

Networking isn’t just for nurses in business – it’s for every single nurse and nursing student out there!  People land jobs because of networking, not just through having a good resume… and these conferences are GOLD MINES for networking.  Do this on social media with the conference tags, in sessions, and at social events.  Have a business card ready to hand out and your up to date resume handy or on your computer, just in case you run into someone who may be able to connect you to an amazing opportunity.  You never know who you’ll meet.  I love to use Staff Garden to keep my resume up to date as well as stay on top of all of the latest job openings.  Click here to create your e-portfolio for free. You can keep it updated constantly and just print or one whenever you need it.

Medication Administration Basics for Nursing Students

Medication Administration Basics for Nursing Students

One of the major things you learn in nursing school is how to give medications. I’d like to explain some basic things because when I was in school, no one told me this stuff.. it was just assumed we knew all of this.  So here are some basic, yet essential, things to know about giving medications to patients. So let’s go over some medication administration basics for nursing students.

Why these meds?

One of the most important things to know is why your patient is taking these specific medications. So take a look at their diagnoses and their medical history to identify why they might be on them.

Also, if you’re looking up medications and can’t figure out why the heck a medication was prescribed, never fear! Sometimes patients take things for an off-label use. So don’t forget to take a peek at off-label uses for the medication before you freak out.

Typically nursing students have to look up the meds that their patient is on the night before their shift.  Therefore, you’re looking things up without physically seeing them.

Quick tip: if it’s something weird that you’ve never heard of or it mentions percents of fluid… it’s probably some sort of intravenous (IV medication)


There are a few different ways you can give meds.  These are the most common.. there are a few others that I won’t go into now because we’re talking basics.


Orally.  Easy enough, right?


IV push

IV push, meaning you have a syringe of the medication and you push it directly in their vein.  If you’re not sure how quickly you can push something, look at your medication reference guide.  Most meds are to be pushed around 1-2 minutes, but always check!  Sometimes you need to reconstitute with some normal saline, but most IV push meds are ones that you draw up from the vial and administer without diluting/reconstituting with saline.

IV infusion

IV infusion meaning it’s going through their IV and typically set up on an IV pump to deliver the appropriate amount at the appropriate rate.  So, if the order says to infuse normal saline at 75 ml/hr, you’re going to grab a liter bag (1000 ml) of saline, prime your tubing, and hook it up to your pump.  You will program your IV pump to administer 75 ml every hour.  Then flush your patient’s IV with a syringe of normal saline, attach it to your patient’s IV, and press start.


IV piggyback

IV piggyback (IVPB) means you hook it up at the port before the IV pump on your maintenance fluid (or a dedicated medication line).  You set the appropriate rate for the medication to infuse (so 100 ml/hr, 200 ml/hr, etc.) and once it has infused all of that medication, the pump automatically flips back to the main line fluid to flush it through to make sure all of the medication was administered.  (This may vary from facility to facility, but this is how these are commonly administered.)


A patch on their skin.  Pretty straight forward.


This means under the tongue.  Again, not too bad!


Rectal. Um. Yea. I probably don’t need to explain that one, right?

IM injection

As a floor or ICU nurse, you don’t give these too often.  They are usually immunizations, but there are a few others you may give.  Typically given in the arm or – gasp – the tush area!  I’d look this up prior to giving one to insure you’re doing this correctly, referencing appropriate landmarks and using the correct technique, as it differs depending on the site.  I’ve probably given less than 5 in the last year, honestly.

Subcutaneous injection

This is very common.  The most common med given this way is insulin!  So, so much insulin.  Another common one is subcutaneous heparin (for DVT prophylaxis).  You’ll give so many insulin injections, you’ll lose track after the first two weeks.  It’s a smaller needle and you pinch some skin in various approved areas and inject.  It’s very simple but can be intimidating at first.  Again, take a peek at your clinical handbook prior to doing this!


When you’re giving IV medications, it’s important to insure everything is compatible. What does this mean?

When IV fluid is running, it is running through a primary line. So their primary IV fluids (normal saline, half normal saline, D5, D10, normal saline with potassium added, etc.) are the main fluids running. When you need to hang an IV antibiotic, you typically “piggy back” (hence the term IV piggyback) this onto your primary fluids, provided they are compatible. The antibiotic is then considered a secondary line. It is connected to the primary tubing. You set the pump to run your antibiotic at the prescribed rate and then it will (typically) automatically switch back over to your maintenance fluids.

For example, if my patient has normal saline with 20 mEq of potassium chloride running at 75 ml/hr and I have a dose of Ancef due, I need to check to see if my normal saline with potassium chloride is compatible with Ancef. If it is not compatible, then I need to start another IV or if they have a PICC line (peripherally inserted central catheter, midline catheter, or central venous catheter), I have to use a different port.

However, please make sure to follow your hospital’s policy because some require people have a dedicated line just for antibiotics (typically called a “med line”), rather than piggybacking it to a maintenance line.

Another thing to consider, as mentioned in the comments below by Katie, is if the maintenance fluid can be paused to administer the antibiotic.  Think to yourself, do I want this paused for the duration of that antibiotic?  Is that okay?  If you have someone on an insulin drip and you’re piggy-backing Zosyn (which can take 4 hours to infuse) on their only dextrose source, you’re going to have a mess on your hands.  I typically only piggyback things to maintenance fluids like normal saline.

To crush or not to crush

Many patients cannot swallow whole pills. This is typically due to impaired swallowing. I don’t mean to brag, but I am a fantastic applesauce mixologist and can get even the grumpiest patients to take their meds. However, before you crush medications you must know if they can be crushed! If it is an extended release med, chemo, or capsule.. don’t crush it!

There are also some meds that for whatever reason cannot be crushed. Depending on the medication administration process at your hospital, your EMR may tell you when you can and cannot crush your med. However, you must be diligent before crushing and double check before doing so.

Overwhelmed much?

There are so many medications for nurses to learn, but don’t lose hope! No one expects you to know all of the medications ever made, their dosages, interactions, trade and generic names, etc.

You’re just building the medication foundation right now – and you’re not just building a house, you’re building a skyscraper.

When you get out of school and start your first job, you will get very used to the medications you give day in and day out. You will learn them inside and out. If you’re a cardiac nurse, you will know Amiodarone, Lopressor, Cardizem, and Epinephrine. If you’re an L&D nurse, you’ll know Pitocin and Magnesium. If you’re a neuro nurse, you’ll be rocking 3% saline, Mannitol, and Keppra. Once you know what you need to focus on, I promise it will get much easier.


More resources


  • Updated Dec 22, 2015
  • Updated Feb 15, 2017
  • Updated Oct 25, 2017
Guest Blog:  10 Steps to Getting Hired as a New Grad Nurse

Guest Blog: 10 Steps to Getting Hired as a New Grad Nurse

Thank you kindly, Kati, for inviting me to guest post on your wonderful and informative site that helps nurses be the best they can be. I’m honored.

I’m Nurse Beth, and I blog at  I’ve enjoyed many nursing roles, one of them being Nurse Manager, which provided me with lots of interviewing and hiring experience.

My passion is helping new nurses. One, because it’s so tough out there to land a job, and two, well, because I love new nurses and their energy.

I know how the hiring process works, and I want to help new grads get started in their careers.

Here’s what you need to know about getting hired from an insider!

1. You need a strategy to get hired as a new grad nurse

Many new grads are discouraged and panic once they discover it’s not easy to get hired.

You have to stand out. That’s your hiring strategy.

Getting Hired as a new grad nurse

You have to Stand Out to get hired as a new grad nurse

At every contact point with your prospective employer, you have to stand out from the hundreds of other applicants.

2. Job Seeking is your Job

Let me ask: Is job seeking your full time job?

  • Have you studied and rehearsed your interviewing skills as much as you’ve studied for anything in school?
  • Have you gone outside of your comfort zone in your job seeking endeavours? Yes? When? What did you do? see, I’m tough 🙂
  • Do you get up early Monday through Friday, dress in business casual, and devote eight hours to getting a job?

Once  job seeking becomes your full time job, you will see results.

3. Beware These Easily Avoidable Mistakes

Here are some basic easy fixes.

  • Having an unprofessional email contact easily remedied
  • Having grammatical errors anywhere on application no excuse
  • Failing to follow application instructions to the letter fastest way to the shredder
  • Not smiling during an interview confident candidates project warmth and openness 
  • Offering a weak handshake at interview passive and insecure
  • Not making eye contact during interview confident candidates get the job
  • Not having knowledge of the company at time of interview savvy candidates are prepared 

 4. Smart Resumes Stand Out

Stop them cold with your savvy resume. If your resume doesn’t stand out, it doesn’t matter how perfect you are for the job. You won’t get an interview. Wow them even though you are a new grad with limited experience.

  • Customize. If you are applying to five different employers, you need five different resumes.  Target to each employer by modeling the language of the job description using their keywords 
  • Visually appealing layout and use of white space. One page long, mistake-free. Clean, neat, easy to read format.
  • Highlight relevant accomplishments, volunteer work, projects, honors, that illustrate how your skills match their needs.
  • Avoid cliches. Everyone is self-motivated and detail oriented. Instead give examples “Led senior class in a community project to educate public on handwashing”

5. Creative Cover Letters Stand Out

Your cover letter lures them in. Captivate them with a creative headline, make them nod at a personal story, and make them want to reach for the phone to call you in for an interview.

6. Interview to Win

If you are interviewing but not getting called back, the problem is most likely your interviewing skills. Interviewing is a learned skill.

The candidate who interviews the best is the candidate who gets the job. 

Many new nurses mistakenly believe that if they have a Tele interview, they should review Arrhythmia. Or to prepare for an Oncology interview, cram the night before on chemo medications. Wrong. They are not looking to see if you have in depth knowledge of a speciality. They know you’re new.

They are looking to see if you are safe, and if you fit in. It’s really as simple as that.

Interviews are often panel interviews consisting of the Nurse Manager, Clinical coordinators, and staff RNs. After the interview, the Nurse Manager will turn to them and say “Well, what did you think? Will he/she fit in?”

Nursing units are a group, a family if you will, and Nurse Managers  want to make sure you’re a good fit. Fitting in is about projecting warmth, opennness, and learnability.

Clinical Scenarios During an Interview

They’re not going to trick you with clinical questions. Commonly they will describe a patient scenario where the patient is in some kind of distress. No matter what the clinical details, they are really looking for responses that show you are competent and safe. Here’s what to say:

  • You stay with the patient shows a safe nurse who doesn’t panic
  • You call for help shows you knows your limitations (rated most important by many interviewers)
  • You initiate any basic interventions (example, apply o2, re-position: cue from the scenario) shows basic clinical competence
  • Bonus points: You anticipate what the provider will order (EKG, labs) shows critical thinking

Prepare for Behavioral Interview Questions

Anticipate that the bulk of the interview will be spent on behavioral questions. Prepared candidates will not say “I’m a perfectionist” when asked “What is your Greatest Weakness?” It’s a cliche and a cop-out. A prepared candidate will be ready with a valid weakness that is not a core skill for the job, and quickly segue into the positive.

Are you prepared for “Tell me About Yourself?” Use the Present/Past/Future model. Tell them where you are now, mention your previous positions, and close with saying  you’d like to work for them in the future. Not rambling takes practice.

Within twenty-four hours after the interview, send a handwritten thank you note. This common courtesy is not so common, and will make you stand out.

7. Networking Nets Jobs

Networking is one of the best ways to get a job. Contact clinical instructors. Clinical instructors are well connected and have Nurse Manager friends. Contact classmates who graduated before you or with you and have a job.

Reach out at church or the gym to find other nurses and start talking. Join a professional nurses’ organization. Volunteer and make contacts.

 8. Risk-takers Stand Out

Some of these are risky, and only you can weigh the personal risk/benefit. Ask yourself: “What do I have to lose?”

  • Consider relocating as the nursing need is geographical.
  • Cold call a nurse manager. Respectfully, with resume in hand “I just wanted to drop this off in person.”
  • Use humor sparingly in your resume or cover letter to stand out. “I love Nutella” under Interests
  • Call HR. Applications get lost, it happens.
  • If you’ve had interviews and not been selected, call and ask for feedback on your interviewing skills.

9. If you are a nursing student, even better 

Work as a PCA in the hospital you want to get hired in as an RN. You almost certainly will get hired with your home field advantage.

Smart nursing students understand that clinical rotations are a time to be seen, make contacts, and stand out.

Getting hired as a new grad nurse

New grad nurses get hired every day

10. Never Ever Ever Give Up

Tolerate this uncomfortable and ambivalent stage in your life with patience and grace. This too, shall pass.

Remain hopeful-you didn’t come this far to fail. You will succeed!

Remember, new grads get hired every day- and with a solid hiring strategy, you will, too!

Again thank you, Kati and all your wonderful nursey followers!

If you enjoyed this post, please stop by and read:

Uncensored Thoughts of a Nurse Interviewer: from Inside the Interview Room 

How to Answer “Why Should We Hire You?”

Nurse Beth

Noticing Subtle Neuro Changes for Nurses

Noticing Subtle Neuro Changes for Nurses


Subtle Neuro Changes

Neuro changes are tough!  It is really hard to know if someone is truly changing or if they’re just exhausted because we keep waking them up.  Here are some of my neuro nurse tips..

Neuro nurse tips for newbies

If your patient is in the intensive care unit, intubated and sedated on propofol, and you need to complete a neuro assessment, you MUST pause the sedation for an accurate assessment.  The only time that we do not pause the sedation is if we have a specific order from a physician not to do so (for example, for a patient in status with propofol infusing for seizure suppression).  Otherwise, all patients need to have their sedation paused for all assessments.  You cannot accurately assess someone’s neuro status (whether they’re a neuro patient or not!) with propofol infusing.  This usually takes about 5-10 minutes for it to wear off to a point where you can get an accurate assessment.

I usually press pause on the propofol right when I start getting report from the night nurse, so by the time they’re done talking, I can get a good assessment done really quickly with the nurse still there and turn it back on right away.

Herniation doesn’t heal

If they stopped following commands, you must elicit pain to see how they respond. Neuro nurses are really good at sternal rubs, trap pinches, and nail bed pressure.  I know this sounds barbaric and mean, but if they do not respond to that and they were responding before, that is a major change.

Make sure you give them enough time to respond to your painful stimuli. It can take as long as 30 seconds for it to register in their brain that they’re in pain and that they need to do something about it.  Pinching a trap for 1-2 seconds and charting that they don’t respond to pain would be inaccurate.

I’ve gone to check out a patient for someone before that was worried because the patient wasn’t waking up like they had been. So, I called out their name, grabbed their hand, shook their shoulder… no response.  The next step is a sternal rub. You’d be surprised how much this will wake someone up who is not changing neurologically!  This will wake patients up that are annoyed with you, ignoring you, or just sleepy and not having true neuro changes. Again, I know this sounds mean but it is essential. If they don’t respond to a sternal rub or other acceptable forms of painful stimuli, the doctor needs to know, like, STAT.

Assessment tips

  • Give them credit where credit is due.  When you’re scoring the Glascow Coma Score, you need to give them credit for their best response.  So if one arm localizes pain and the other has abnormal extension, they get credit for localizing.
  • Don’t give pain meds or sedation unless it’s absolutely necessary.  These meds will make the patient more sedated and therefore it will be more difficult to tell if they’re having neuro changes.
  • Make sure you explain to the family what you’re doing before you use painful stimuli. Also, always warn the patient.  My go-to line is:  “Mr. Smith, you’re about to feel some pressure!”  ((painful stimuli)) “I need you to come get my arm and stop me!”
  • Notice spontaneous movements.  Are the movements purposeful (meaning, are they doing things that makes sense like reaching for their ETT or scratching themselves) or are they just spontaneous non-purposeful movements?  The physician needs to know this.
  • Don’t just let them sleep all day and defer your assessment because they seem to be resting.  They may not be resting, they may be obtunded.  I know it sucks waking someone up all the time, but we have to do regular assessments to see if they’re changing.  Always warn these patients on admission that we are going to be waking them up frequently.
  • “That’s how they’ve been all day,” is not an assessment.  If they look the same as they did this morning when you got report from the night shift nurse, that still might not be good. Are they following commands?  Are they waking up?  Are their pupils reactive?  Does the family think they’ve changed?  Are they engaging in conversation?  Etc, etc.
  • Always ask direct orientation questions to patients that seem to be with it. Patients can carry on a normal conversation, but then you ask them what year it is and they reply with, “Well, it’s Ju-ly of 1942 of course!”  Make sure you ask direct questions.
  • What’s their sodium? Hyponatremia can make people super lethargic.  So if it’s been 24 hours since their last BMP and their sodium was 133, they may have dropped. It’s amazing the difference a little salt can make in someone’s level of consciousness.

Talk it up

The mark of a good neuro nurse is not only solid assessment skills, but also being able to articulate it to the physician, PA, or NP.  It’s really hard for them to decide what orders to put in if you call them with vague changes.  Know specifically what they were doing before, what change occurred, and how to communicate it to the provider.

In addition to knowing specific neuro changes, make sure you have other pieces of key information for the physician.  Know when their last head CT or MRI was – what did it show?  Pull up the scan, look at the stroke/tumor/mass and think about what assessment you should find with an injury in that area.  If you’re calling about seizure activity, be able to articulate exactly what they did and how long it lasted.

Know the patient’s lab values (neurologists/neurosurgeons care about a patient’s sodium like cardiologists/cardiothoracic surgeons care about potassium), and any meds they have received that could have affected your neuro exam.  Also, know if they’re on a steroid, mannitol, or an anti-epileptic (med for seizures).

Something that’s important is to warn the patient and their family when they are admitted what they’re in for.  This also will keep you from feeling bad for waking them up – it’s part of the job!  Here’s my general “welcome to no sleep” speech:

“While you’re here with us in the hospital, we are going to wake up frequently to make sure things in your brain are not changing.  When your brain changes, it doesn’t show up on the monitor or in your vital signs, it shows up in these little tests/assessments that we do frequently and that’s why it’s really important for us not only to do them, but for you to do the best you can with each assessment.  We will be asking you to do the same things over and over again, but it is very important to see how your brain is doing.  Take advantage of the times that we’re not in here to nap and we’ll do the best we can to cluster our care to allow you time to sleep.”

When to freak out

There are some emergent neuro nurse situations.  Keep in mind, there are *usually* tons of warning signs (however, some people herniate very quickly, before anything could be done even if you knew what was going on).

Blown pupils (4-6 mm, non reactive) are late neuro changes.

Vital sign changes (sudden hypertension and bradycardia) are very late as well.

If the patient is not intubated and you’re noticing periods of apnea or worried that they’re not protecting their airway (new snoring, agonal respirations, etc), call the MD because they may need to be intubated.  If you’re waiting for an SpO2 to drop before becoming worried about their respiratory status, you’re just waiting to call a code.  Always make sure the patient is protecting their airway – this is a neuro issue, not a lung issue.

If you’re just letting your sedation ride all day, waiting for pupillary changes to occur to call the doctor about neuro changes.. that’s basically saying, “I’m going to wait until my patient herniates before I do anything about it.”  You cannot be reactive – you must be proactive.

When brain cells die, they die. It’s a big deal if you miss something because it’s not like you can un-do that. Blood pressures can bounce back, hearts can be restarted, clots can be removed, but when brain cells are gone.. they’re gone.

Pause sedation.  Assess your patients.  Communicate to physicians appropriately.  Educate your patients.

Neuro nurses unite!

Need more in-depth neuro info? Check out the Neuro Nurse Crash Course brought to you by FreshRN® where we discuss essential topics like essential neuroanatomy and disease processes, primary and secondary injury, neuro nursing report, meds, time management, mastering the neuro assessment, and more!

Enroll in Class

More neuro resources

FreshRN Podcast episodes specifically related to neuro:

NRSNG Podcast Episodes specifically related to neuro:

Neuro-specific blog posts:

Some books:


The NeuroICU BookThe NeuroICU BookMarino's The ICU Book: Print + Ebook with Updates (ICU Book (Marino))Marino’s The ICU Book: Print + Ebook with Updates (ICU Book (Marino))Becoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and YourselfBecoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and Yourself



Guest Post: Giving a Voice to the Silent Sufferers

Guest Post: Giving a Voice to the Silent Sufferers

As Domestic Violence Awareness Month comes to a close, I wanted to feature a guest post about the topic.  It’s important that we, as nurses, are keenly aware of the prevalence of domestic violence, how to identify it, what to do, and how to care for ourselves.  If you have a personal nursing experience related to this, please feel free to share it in the comments section.  I think it’s important to share information regarding how to handle this when we see it in our patients.. what worked?  What didn’t?  What will you always remember?  What helpful hints can you give newbies?  (Please remember to keep all information HIPAA compliant)


Did you know that, on average, 24 people per minute are victims of rape, physical violence, or stalking by an intimate partner? Or how about the fact that nearly 1 in every 10 women in the United States has been raped by an intimate partner in her lifetime?

Domestic violence is extremely prevalent throughout society, yet many people don’t quite understand just how rooted it is in our culture. Many victims of domestic violence are afraid to talk about their abuse for a variety of reasons including fear, threats, coercion, or lack or resources. Because of this, nurses play an essential role in identifying the signs and symptoms of domestic violence, and giving victims the support and resources they need to leave their abuser.

Recognizing the signs of domestic violence is not an easy task – while there are some more obvious symptoms (bruising that doesn’t match the explanation the patient gave, broken teeth, a history of broken bones), many symptoms are not easily identifiable and can require a nurse’s full sensory awareness. Some of these symptoms include:

  • Strange or intimidating behavior between the patient and partner during the visit
  • Signs of patient fear from his or her partner
  • A history of drug and/or alcohol abuse from the patient and/or partner
  • The partner trying to dominate the visit and not allowing the patient to speak for his or herself

If a nurse notices any of these signs or symptoms, it’s important to carefully and sensitively follow-up with the patient regarding the possibility of domestic violence. This should be done in a safe, private area away from the abusive partner. If your concerns are confirmed by the victim, giving the victim options of local government organizations, religious groups, and community nonprofits is one of the best ways to guide them towards leaving their abuser. Counseling services, emergency services, and housing services are all resources that can easily be found online. If a victim is hesitant to leave their abuser, simply providing a web address to one of these services could be enough to resonate with the victim and eventually help him or her make the decision to flee his or her abusive relationship.

Treating a patient who has been a victim of domestic abuse can be very psychologically challenging. It is not uncommon for nurses to feel extremely affected by seeing the damage an intimate partner can do to someone he or she is supposed to love. After the patient has been discharged, nurses should try to be very in-tune with their emotions; if one starts to feel down or depressed after treating a victim of domestic abuse, one of the best things to do is talk about it with a peer or write it down. Research has shown that this is one of the most psychologically beneficial things individuals who have been through a harrowing situation can do.

Preparation is key when treating a patient who is the victim of domestic violence. By understanding the proper way to handle the situation – both for the victim and personally – nurses can help ensure that everyone involved takes the necessary steps towards leading a safe and healthy life. Nurses see many traumatizing things in a day, but sometimes the most traumatizing situations are where the victim is silently suffering. By raising awareness for domestic violence, we are giving a voice to the millions of victims who aren’t yet ready to speak about their abuse.

If you or someone you know is experiencing domestic violence, it may be difficult to know what to do. The National Domestic Violence Hotline has highly trained advocates available 24/7 to give you anonymous and confidential help. Call 1-800-799-SAFE (7233) or visit

Carly Dell Headshot

Carly Dell is the community manager for the innovative online rn to bsn program offered through Simmons College. In her free time, Carly enjoys traveling, binge-watching HGTV, and trying new restaurants. Follow her on Twitter @carlydell2 and Google+.



You’ve heard of Life Hacks?  Well, here are my NURSE.HACKS.

  1. Put 1-2 drops of normal saline (from one of the hundreds of flushes you accidentally bring home) in your mascara that’s starting to dry out. That’ll moisten it up and make it last longer.
  2. Contacts hurting or dry at work? Grab a flush and irrigate your eye. It’s the same as your solution at home, minus some of the extra ingredients to cleannursehacks the contacts overnight.
  3. Isolation gowns are great for protecting your scrubs during messy meals.
  4. Double or triple glove when heading into a serious code brown situation.
  5. If you have a really chatty patient or family member and are in a big time crunch because your other patients need you, ask someone to come in and grab you after ten minutes.
  6. Patient getting a bedside central line and feeding tube placed? Wait and get both xrays at the same time.
  7. 0700, 0800, and 0900 meds? Ask the patient if they normally take them together at home – if they do, give them all at the same time and chart patient request for the reason you’re giving them early. Use nursing judgment though; some meds are purposefully scheduled that way (blood pressure meds or meds that must be given on an empty stomach or with meals).
  8. Coffee grounds can absorb even the stinkiest of stinkies. Throw a bag of coffee grounds in one of those useless tiny emesis basins and set it in the room to be sneaky about your odor absorption.
  9. Soak your dobhoff tube in ice water for a few minutes before insertion; it stiffens it up and allows it to glide through their nasal passages easier.
  10. Can’t find a vein? Warm up a moist washcloth and set it on their skin for a few minutes. This can make veins pop better than a tourniquet!
  11. Super sad or grumpy pa3tient? Many hospitals have therapy dogs. See if the patient likes pups and arrange a surprise visit! You could even see if you can get a dog that is similar to one they may have at home.
  12. Can’t get a female foley? Have someone hold a pen light, aim high, and if you don’t get return just leave it in place and grab another and aim higher! If you’re worried you won’t get it, bring a few extra in the room before you start.
  13. O2 sat won’t pick up? Try the earlobes or toes!   The neonatal O2 probes are awesome on adults. They stick better and are less bulky.
  14. Can’t get a blood pressue on a patient in afib with an elevated heart rate? Get a manual pressure. Uncontrolled afib is hard for those automatic cuffs to read properly and probably isn’t accurate anyway.
  15. Family and/or patient very emotional or upset and don’t know what to say? Your presence can speak louder than words. Just being there with a reassuring shoulder pat or taking really, really good care of their loved one will mean just as much, if not more, than saying the perfect thing.
  16. Confused patient picking at EVERYTHING? Activity aprons are a Godsend. Move the O2 probe to their foot. Put their ECG leads on their back (not for an extended period of time due to skin breakdown). Give them something to do, like fold washcloths.

What other NURSE.HACKS do you have to add to the list?  Tweet me / pin / tumblr post some of your favorite nurse hacks with the #nursehacks hashtag!  I’ll make an awesome master list to reference.


Becoming An Awesome Nursing Preceptor:  Phase Three

Becoming An Awesome Nursing Preceptor: Phase Three

This is my third and final post in my nursey series about precepting new graduate nurses.

Here’s the link to the first post.

Here’s the link to the second post.

Thanks for catching up!  Onward..

Once your orientee has mastered caring for 1-2 patients, it’s time to start putting the on the heat. Phase three is where you begin to back away completely and they are running the patient-care show. They should become more confident in completing tasks and starting to think more and more about the big picture.

They should be able to anticipate obstacles. They should be figuring out their time management style. They should be appropriately discussing the plan of care with other members of the health care team. They should be delegating appropriately.

What I like to do in this phase is really step back. I have a little conference at the beginning of the shift right after report and outline our goals for the day. When deciding on goals, I think about the things they are struggling with and make those the priority.

Your goals need to be measurable so at the end of the day you can say whether or not they met the goal and discuss why. I try to stick with 3-5 specific goals.  I didn’t mention this before, but I do this goal-setting throughout the entire process.  I also document this every shift using the same sheet.  I save them, go over them at the end of the week with the orientee and we both sign them saying that we agree with we’ve discussed.  This protects you if they do not progress appropriately and you need to be able to tell your manager why.   This will help your manager determine the appropriate next steps.

Example: “Alright, today starts week 7 and we have a few goals today. First, I want you to make sure you’re acknowledging new orders that come through within 1 hour of them being placed. Our second goal will be to give all medications on time unless extenuating circumstances present themselves. And our final goal is to delegate appropriately all day today so that you are working at the top of your license consistently. At 1100, I will check your charting. At 1500, we’ll see where we are with our goals and what we can do or change to insure we’re on track to meet them. If you encounter any roadblocks, please come ask me.  However, want you to try to be as independent as possible.”

Whenever they come up to me to ask a question, I basically ask the question back to them to see what their thought process is. Typically at this point they know the answer and they just need reassurance.  And if I can tell they always know the right thing to do but just want me to confirm it’s right, I don’t reassure them.  They need to learn to trust their thought processes and critical thinking, so not giving them the reassurance is what they need to push them to be independent.

Additionally, while they’re figuring out their own time management, I let them drown a little. When I talk to them at 1100 and 1500, I talk about things I observed that could have been done more efficiently to save them some time.  I also look at how they prioritize their tasks and if there’s any room for improvement.  The tendency is to do things that they know how to do first, not necessarily the things that are the priority.  For example, if they need to hang a unit of blood or go give scheduled PO meds early.. they’ll probably head to give the meds first.  Redirect them as needed.

It’s important to empower them to take responsibility for their patient load as soon as possible.  The scariest part of being out of orientation is knowing that you are ultimately responsible for your patient’s well being without anyone checking behind you.  The earlier you can empower them to take responsibility for them, the better.  When giving and getting report, make sure the off going nurse is giving report to your orientee and not you.  Make sure they’re paging the physicians and rounding with them.  Whenever any asks any questions about the patient, refer them to your oriented and say that they are the orientee’s patient, not yours.  At this point, you’re in the background to help PRN and to double check behind charting and task completion.

Furthermore, praise is super important in all of these phases. It is really sacry and humbling to be a brand new nurse.  You’re constantly being told you’re wrong. So when they do something well or right, make sure they know it. It can go a long, long way.

If throughout this entire time you’ve been giving them homework and quizzing them on issues that face your patient population, you’ve really sown a lot into this brand new nurse. You’ve set them up for success. Not only that, you’ve set them up to be an awesome and reliable coworker. If you take the time to sow into them confidence and solid nursing skills, it’s a win-win situation.

Precepting a lot of work, especially at the beginning. You really have to be on top of them, teaching, encouraging, and holding them accountable. It can be a really rewarding experience.

However, not everyone is keen on doing things the way they need to be done during the orientation process. Stay tuned for an upcoming blog post about how to deal with people that aren’t progressing through orientation appropriately!

If you are an awesome and experienced nursing preceptor, please comment below!  I would love to hear about your routine and things that you do to insure your nursling is ready to be out on their own.

Becoming An Awesome Nursing Preceptor:  Phase Two

Becoming An Awesome Nursing Preceptor: Phase Two

Hello good friend!  Welcome to my second post in a series of three about how to become an awesome nursing preceptor.

Please keep in mind that this is aimed towards the orientation of a new graduate nurse on a general medical-surgical floor.  However, it’s pretty general so it can be adapted to fit the needs of speciality units.

In my last post, we discussed the first phase of orientation. Here is the link:  Becoming An Awesome Nursing Preceptor:  Phase One

I’m now going to discuss the ever-important second phase of the orientation process.

Phase Two:

During this phase, they’ll take a patient on their own. After seeing how you take care of a patient, they should be able to adequately care for one person while you’re nearby for questions.

They will take and give report on their patient. They will do everything for them, even call physicians and support staff, as needed. They will complete all of the documentation. They will talk to their loved ones. They will educate the them.

Again, if they don’t know how to do something, always direct them to the policy first. With one patient, they should have time to go look up the policies for everything.

Continue to give them homework. Print off information about your patient population and quiz them the next day.

During this time, I start to ask all of my why questions.  Depending on their progression and knowledge base, I try to challenge them with the questions.  I also try to think of questions that patients may ask about their care plan.

  • Why do you think they’re on subcutaneous heparin?
  • Why are they on Colace and Pepcid?
  • Why do we need to do a bladder scan if they didn’t void 6 hours after you removed the foley?
  • Why do you think you needed to put your patient with CHF on oxygen after he got two units of blood?
  • Why do you think we need a central line when initiating vasoactive medications?
  • Why is it imperative that you lay them completely flat when removing their PICC line?
  • Why are we still giving them IV pain medication when we have oral pain medication ordered?

Whenever they ask me a question, I just ask it back to them to see what they think. I want them to develop their critical thinking skills. We need to go from being task-oriented to being big-picture oriented. While developing these skills, it’s important to not give away the answers quickly.  Let them think.  Furthermore, if other members of the health care team (docs, MD’s/PA’s, CNA’s, etc.) ask them questions about the patient, don’t answer for them.  I’m terrible at this.  I have to try really, really hard not to answer for them.

You want to encourage them to ask questions, so don’t act like they’re stupid if they get one wrong or do something incorrectly. Handle those situations with grace. Please don’t use that opportunity to make someone feel bad about themselves.   That’s that terrible nurses eating their young thing.

It is really important that during all phases of orientation that you are treating everyone around you with the utmost respect.  If you are talking badly about other people in front of your orientee, they see and hear that. If you’re not being respectful of the CNA’s, you’re telling them it’s okay to do that. If you are nice to someone’s face and once they leave you talk about them, you’re not being a good role model to your orientee.  They are watching how you do everything, including how you interact with others.  If you want them to be a good nurse and supportive coworker, it is imperative that you model that yourself.

Amazing nursing preceptors out there – what is your routine with your newbies once they get their nursey feet under them?  What tips/tricks/advice do you have to share?  Please comment below!


Becoming An Awesome Nursing Preceptor:  Phase One

Becoming An Awesome Nursing Preceptor: Phase One

I was very fortunate to have some amazing preceptors both when I started nursing and again when I transitioned into critical care. I’ve also had the privilege of precepting people myself. I pray I was a tiny fraction of the awesome that my preceptors were to me.

Because of an awesome question I received via my Tumblr (, I am writing a three-part series on the process in which I have been precepted and also how I’ve done it myself.  It is much more involved and requires planning, patience, and grace.

When I look at orientation, I divide it into three chunks. All three require different levels of assistance that you’ll give your orientee. I’ll go through each of them in a series of three posts. The duration of each phase depends on the entire length of their orientation as well as their personal progression. As a rule of thumb, phase one is the shortest and phase three is the longest.


After 2-4 years of learning that everything is important in nursing school, your job as a preceptor is to get them to focus on what is important for your patient population.

Something to keep in mind is your newbies will be entirely task focused. This is the normal progression. They will be focused on completing tasks, not critically thinking/anticipating problems. Again, this is how it should start. We will add the critical thinking piece later.

Phase One:

The first few shifts are utilized for observation. They need to see the flow and culture of the unit and patient population. The patients are still your patients, however your orientee is going to be given tasks to complete, all while getting familiar with the flow of the unit.

During your patient care, have them perform simple tasks; drawing up medications, calculating dosages, administering IV/subcut medications, starting IV’s, putting in feeding tubes, documenting appropriately, using foley insertions, putting people on telemetry, etc. When they ask how to do certain things, show them how to look up policies and procedures. You’ll find yourself saying, “what does the policy say?” over and over again, but you need to get them into that habit.

Another important thing to remember is to give your orientee a consistent routine.  Once they’re out on their own they can start to improvise and change how they manage their time.  But right now they don’t know what all of their options are so they can’t make an appropriate judgement on what they like best.  During phase one when you’re showing them the ropes, show them your awesome and efficient time management skills, and your routine of how you walk through your day.  They can decide what they like and what they don’t like for themselves once they’ve gone through it a few times in the later phases.

Something that expert nurses forget (because they’re experts!) is the “why” behind everything.  The things we do become so normal and natural, we just don’t have to think about the “why” anymore.  Remember, these newbies need to know the “why”.  This is important in their professional development into a safe care provider.  Even if it seems menial, you must explain the “why” behind everything.

Things you need to do in Phase One

  • Formally introduce them to everyone. CNA’s, MD’s, PA’s, NP’s, transporters, etc. They are now part of your team and what better way to welcome them and make them feel part of it all than by you taking the time to introduce them to everyone.
  • Explain your time management technique and why you do things in the order that you do them.
  • Explain your prioritization that is ever-changing throughout the day.
  • Demonstrate appropriate delegation as well as accountability when tasks are delegated.
  • Have them observe how you interact with patients/families, physicians, and support staff.
  • Get them familiar with documentation.
  • Have them take report right along with you so they can choose the report sheet they want to use and get familiar with it
  • Get them familiar with your IV pumps and tubing.
  • Find information specific to your patient population, print it off, and have them read about it at home. Quiz them on it the next day. Start building that foundational knowledge about the disease processes that affect your patients.
  • Show them how to look up policies and procedures.
  • Get them familiar with the house phone numbers and departments. Take them wherever you go in the hospital to show them around. Again, introduce them to people.

Depending on their progression, this can last 2-3 weeks before you move on.

In my next post, I’ll discuss Phase Two of the nursing orientation process!

Are you an experienced preceptor?  What’s your routine during the first few weeks?  What worked and what bombed?



Landing a Nursing Job: Having an Edge

Landing a nursing job isn’t easy right now for new grads.  The interview is important, but you have to get there first. Out of all of the applications on their desk, you need to stand out.  You need to have an edge.

Here’s my advice on how to get an edge on the competition.. or as I like to call it, a nursey edge on the competition:

1.  Work as a certified nursing assistant (CNA). It’s a certification you can get via adult education courses or at a local college/community college where you provide basic care to patients (baths, take vitals, stock equipment, take patients to the bathroom, etc.) You take the class, pass an exam and BOOM, you’re a CNA. A hospital job would be preferred, but if you can’t, head to the nursing home.

Why should you do this?  You will get experience with patients. You will become familiar with the flow of patient care.  You will get to know nurses, doctors, and leadership. You will get references.  When your RN application comes across their desk in a few years, they’ll know exactly who you are.  It also looks great for first time nurses if you were a CNA for a while beforehand, even if it’s not at the same facility.  And honestly, it’ll make you a better nurse in the long run.

2.  Volunteer. If you’re in school and don’t have time to drop everything and become a CNA, volunteer. Hospitals use volunteers all the time. They use them to escort guests, restock units, help out in the emergency department, deliver mail, etc.  Even if it’s just a few hours a week, it’s worth it.  This is a fantastic way to get your foot in the door, get exposed to working in a hospital, and honestly it’s an awesome experience.  In addition to working for a hospital, there are opportunities in nursing homes and hospice houses.

Why should you do this?  Again, you will become familiar around patients. You will see how the hospital runs. You will get to know people. You will get references.  It looks fantastic on a resume but also, volunteering is just a good experience to have as a person.

3.  Have a flawless resume + cover letter. Seriously, your resume + cover letter should look awesome.  I really like and appreciate this article about resumes:  10 Reasons Your Resume Isn’t Getting You Interviews.  I think a little creativity is great for a resume, but nothing too flashy for this profession.



Why should you do this?  You want people to remember you. Out of a sea of 50 applicants for 5 positions, you need to stand out.

4.  Network. This is difficult to do if you’re not already working at a hospital, which makes working as a CNA and/or volunteering all the more important. Get involved on LinkedIn, try to meet people at work, and spend some time getting to know people and build professional relationships.

Why should you do this?  Good references are essential. When they look at your application and they see that you’ve listed an MD from the Emergency Department (that you got because you volunteered there during the summers in between semesters of nursing school), that stands out.  Furthermore, down the line, you may be able to return the favor and help someone out when they need it.

5.  Complete a nursing internship during the summer. This isn’t available everywhere, but a lot of bigger hospitals have nursing internships during the summer. You have to apply for these early (like January/February), but landing one will be invaluable.

Why should you do this? Again, you’ll gain experience in the hospital, caring for patients and their families. You’ll get familiar with the stuff you’ve only read about in school.  You’ll network. You’ll establish a relationship with your manager and coworkers on the unit, who then turn into great references.  And if you want to work in that hospital after graduation, you’ve already laid the groundwork.  They know who you are, they just need to ask the previous manager what they thought of you.  So make a good impression!

A few additional important things to remember:

  • Now BSN’s are always preferred.  If you are an ADN nurse, present a timeline for when you plan to complete your BSN.
  • Don’t look crazy on social media.  They WILL look you up and if you look like someone they don’t want to represent their company, you will not get an interview.
  • Don’t have an email address from middle school (no, is not professional).  Spend the 30 seconds it takes to get a Gmail account with your name in it.  Use caution when putting your school email on job applications.  Typically after you graduate, you’ll lose that address.  If that’s the only one you gave them when you applied, you won’t know if they respond if the school closes your email account in the meantime!
  • Don’t be afraid to ask for references or letters of recommendation!  If you work your butt off to help people out at work, typically they’re more than happy to write letters of recommendation or be listed as a reference.

Basically, the people that get hired go above and beyond. They volunteer. They work in a related area. They did extracurriculars in college. They have professional connections who think they’re awesome and will gladly recommend them.

They didn’t just do the minimum and hope for the best.

God speed, nurslings!

Tips for Switching From Night Shift to Day Shift – From a Nurse!

Tips for Switching From Night Shift to Day Shift – From a Nurse!

Many nurses start out on night shift but then transition to day shift.  While the work is technically the same, the flow of the day is quite different.  Here are some tips/tricks for the nurse transitioning from night shift to day shift.

#1 – Pay attention to meds with meals

Insulin is the major medication to take note of.  When you’re looking at what meds you have to give for the day, pay particular attention to AC/HS blood sugar checks with insulin coverage, and any other meds that need to be given with meals and manage your time accordingly.  I got burned on this at first.  I wasn’t paying attention and before I knew it, dietary delivered their tray.   They ate without getting their sugar checked first and they had sliding scale + scheduled insulin due.

Also, keep in mind meds for dialysis or pancreatitis patients that have meds that must be given with each meal and again, manage your time accordingly.

#2 – Try to chart in real time as often as possible

On nights, I’d chart a few things in real time, but once everything settled down, I’d sit down to complete all of my charting at once.  Keep in mind, you don’t always get time to be able to catch up so chart as things happen if you can!

#3 – Anticipate obstacles for discharges

If I find out in report that a patient will probably be discharged that day, I immediately ask them about transportation.  Many times family members that are their rides are only available during certain times, so find out early so you can manage your time appropriately.  Otherwise, they’ll put on their call light and say their ride is waiting downstairs and the doctor hasn’t even put in the scripts yet.  Also, make sure they can pay for their scripts.  Too many times I was giving discharge instructions and suddenly they said they couldn’t pay for their meds, but their ride was already on the way.


#4 – Know what time the physicians begin call

And make sure you get routine needs addressed before then!  This is usually around 1700.  Nothing frustrates on-call physicians more is calling at 1730 for something routine that the attending physician or their advanced practice provider could have easily addressed.  Manage your time so that you have all of the orders you need before it switches to the on-call doctor.  You also want to make sure you do this so you don’t leave night shift hanging.

#5 – Don’t try to get absolutely everything done before you let yourself eat lunch

I would do that on night shift because it was more feasible.  There weren’t any discharges and much fewer admissions.  I would see everyone, medicate them, chart, and round again before I would eat.  This isn’t realistic on day shift because once you’re done with 0900 meds and charting, it’s time for 1130-1200 meds.  Usually you start to get discharges (and therefore admissions) around this time as well, which means you won’t be eating lunch until 1600.  Try to get your lunch whenever you can.

#6 – When family members call for an update, take a message if you’re busy

They like to call at shift change, around 0900, and 1200-1300… you know, the busiest times of the shift. I know, it’s frustrating, but most people don’t realize how big of a headache that is.  Simply, don’t take phone calls mid-med pass unless they’re urgent. That’s when you make errors.  Have whomever answered the phone get a number and call them back, or ask them to call back in an hour.

#7 – Round with the physicians

Do this to build rapport and establish a professional trusting relationship. On night shift, you’re working with on-call physicians typically, getting them to the next day and prioritizing most decisions to be made the following shift with the attending. On day shift, you’re working elbow-to-elbow with the attending physician about decisions, concerns, and plan of care.

Make your face known to them, shake their hand, and give them an update on your patient before they ask.  The nice thing about day shift is you really get to know the doctors.  Having a good relationship with them can make your job much easier.

#8 – Don’t call physicians about non-urgent/emergent issues that can easily be address during rounds

We need to be respectful of their time, as we want them to be respectful of  ours.  If we call for every little need that can be addressed during rounds, it takes them away from other patients.  If it’s something that’s not going to change your plan of care between now and then, wait until they come by for rounds if possible. Consolidation of calls/pages is appreciated by all!

#9 – Don’t linger around, chatting it up with night shift

You’re already behind! Seriously, day shift feels like you just hit the ground running immediately. If you hang back to catch up with your BFF night shift bud, you may already be late on some meds, missing the resident’s pre-rounds, or missed a pre-breakfast Synthroid dose!

Seriously, my first few weeks on days felt like –


#10 – Take some time to touch base with your CNAs/PCTs first

After report, double check to make sure they know who needs a bath today and who has blood sugar checks and if you need to be notified for specific vital signs (for example, for a systolic blood pressure above 160).  Don’t assume the night shift tech gave communicated everything they need to know. Again, been burned here. Never assume anything – double check with your nursing staff, especially those with whom you’re sharing tasks for patients throughout the shift. This also builds rapport with them as well, which is essential because you will rely on them heavily.

Even more resources for new nurses



How to Deal With Gossipy Nurses

How to Deal With Gossipy Nurses


I recently got a job as a new grad in a peds hospital, I love my job but hate the people I work with, they all gossip and talk behind everyone’s back and I’m not sure how to deal with that. I don’t want to seem rude but don’t want to be part of that drama. Any advice? – submitted by Anonymous via Tumblr

That’s the worst – I hate adults that act like children.  A true Nurse Eye Roll moment.

Things to do when that happens:

1.  Don’t respond when they complain/gossip.  They’re looking for a reaction.. any kind of reaction (agree or disagree), and once you provide that, they know they can talk to you about it.  Don’t respond.  Just keep charting or start flipping through your phone.  It’ll be awkward at first, but just push through.  Then they’ll figure out they can’t talk to you when they want to gossip.  I’ve done this, and while it was weird at first, I now get less people complaining and gossiping to me now. Don’t provide the audience for it.  If you are not entertained by their gossip, it’s not enjoyable for them.  Put on your “I don’t care face” and don’t give it any time.

2.  Don’t do it yourself.  When most people start in a new work environment, they want to bond with their coworkers, however don’t do so by gossiping.  Many people bond when they can find a common interest and sadly enough, when people don’t know each other well, they use not liking someone else as an initial common interest (insert another Nurse Eye Roll).  Model the kind of coworker you want them to be.  Be thankful when they help you with stuff, help them out, go the extra mile for them, bring in goodies, and expect nothing in return. Find real common interests (TV shows, movies, hobbies), which provides something to talk about.  Use something like that to establish a friendship and then get an inside joke going or something.  Once I find out the grumpy nurse likes The Office, I act like Michael Scott for an hour or two and before you know it, they’re coming to me when they need help.  However, make sure you have minimal expectations for them to respond.. they may not like the way they feel when you deny their gossipy-ness.  That may rub them the wrong way initially, so don’t be surprised if you get a few cold shoulders.  But hey, that’s fine.  So basically, use those types of actions to bond with them, have minimal expectations for their responses, model the kind of coworker you expect them to be to you, and pray for the best.

3.  Whenever they complain/gossip directly to you and you really can’t just ignore them, change the subject quickly:  ask them about themselves (people love to talk about themselves).  Or point out something good and positive about the person they’re trying to gossip about.  Hopefully that’ll change their mindset and they’ll feel bad continuing to talk so negatively about someone.

For example, things were slow one day and a bunch of us nurses were chatting it up.. you know, the typical calm before the storm.  They started talking about a new nurse.  Every time they said something negative, I had a positive thing to say.  It slowly stifled down the negativity.  And when they mentioned something ridiculous the new nurse did, I mentioned something ridiculous I did when I first started.  I also knew one of the nurses in the group was a fantastic storyteller.  She’s been a nurse for decades in many different settings and always had hilarious nurse stories. So I slowly got her telling stories, and before you know it, she’s entertaining the entire group with hilarious stories and this fresh newbie nurse is no longer the topic of conversation.  (Keep in mind, making a big stance in the moment against this is appropriate at times, but changing a culture of a unit is a sensitive, delicate  process that requires persistence.)

The main thing is to just make sure you’re not condoning or providing an audience.  If you’re not entertained when they talk negatively about people, but you are really entertained and engaged when they talk about last night’s episode of NY Med (insert Katie Duke popping out of a body bag) or Parks and Recreation (insert Ron Swanson talking about how much he hates yoga), that’ll turn into what they talk about with you.  Not people they don’t like.

Good luck.  I hope you can be a positive influence on the culture of your unit!  Remember, it is a slow, delicate, and tedious process but will be worth it in the end!

Calling Docs on Nocs (again)

I decided to reblog this post for all of you that just graduated nursing school, getting ready to start your first real nursing job (probably on nights) that have never had to call a physician in the middle of the night.  The first time you do it, you’ll feel like Neville Longbottom the first time he got on a broom, almost breaking his neck and actually breaking his arm.  After a few shifts, you’ll feel like freakin Harry Potter flyin’ around that Quidditch stadium.  So, pretend I’m that Hogworts Professor we never see again for some reason, teaching you how to hop on your broom for the first time…  


I worked nights as a new grad. It’s great because you have time to learn, but it sucks because the only time you get to know physicians is when you call them in the middle of the night and piss them off. You become the annoying nurse that wakes them up every time they’re on call instead of your best bud.

(HINT – doctors that become your best buds and trust you are AWESOME)

To make it a little less painful, here are some hints.

#1 – Don’t immediately apologize for calling them. Yes, it sucks you had to wake them up, but it’s their job and you’re just doing yours. It’s all business.

#2 – Don’t get nervous and just say the patient’s name and ask your question. This is the on-call doctor, they may not be familiar with your patient. If you’re not sure, first ask if they are familiar with your patient. If they’re not, give them a brief summary of the patient’s main problems.

#3 – Be prepared. Have a fresh set of vitals, know their allergies, have their labs pulled up, anticipate their questions, and be in a quiet area because they’re probably half asleep and will talk softly. If possible, know what order you want. For example, if they haven’t voided in 8 hours after a foley was D/C’d, anticipate an order for a straight cath if their bladder scan shows more than 500 ml. If they’re in terrible pain after a thoracotomy earlier that evening and it’s not controlled at all despite all of your PRN’s, anticipate (or suggest if asked) a morphine PCA on the lowest setting.

#4 – If it’s a recurring problem, ask them when they want to be notified again. If you’re calling because they had a 3 second pause and their heart rate is in the 40’s and he tells you he doesn’t care, ask when he wants to know and write the order.

#5 – Make sure you have scratch paper handy to write down orders. You think you’ll remember it, but then he gives you 4 unexpected med orders and your tech is trying to talk to you while you’re on the phone and now you’ve forgotten them all before you’ve hung up.

#6 – Don’t page and go do something else. Nothing makes them more upset than waiting on hold while you finish getting someone off the bedpan for 7 minutes. I think I’d be grumpy too!

#7 – Ask ALL of your fellow RN’s if they also need to speak with that doctor . Another thing that, rightfully so, pisses them off is multiple calls from the same unit about things that could have all been asked in one call.  Just like we can’t stand being constantly interrupted while passing meds or doing an assessment, they don’t like being interrupted dealing with other patients or finally getting sleep after a really long day.

#8 – If they’re pissy, don’t take it personally. The sooner you figure that out, the better. Doctors can get mad and rude, but that doesn’t have to make you feel like crap for the rest of the shift. Maybe they had a patient they had been heavily invested in die earlier that day, maybe their kid won’t stop crying and he had just fallen asleep, or maybe they’re just awful. But you’re not, so there!



“This is Dr. Smith. Someone paged?”

“Hi Dr. Smith, this is Jaclyn Evans from the observation unit. I have a question about the patient Edward Godwin in room 8123. Are you familiar with him?”

“No. Who the hell is that?”

“He came in yesterday for chest pain and is here overnight for observation. His cardiac work-up thus far has been essentially negative. He is scheduled for a stress test in the morning. His only history is GERD and HTN. I’m calling because he is bradycardic. When awake, his heart rate is 45-50, and when asleep, he’s gone as low as 35. He’s asymptomatic. I’ve also noticed an increase in his PVC’s. He had occasional PVC’s at the beginning of the shift, and now he’s having 25/minute.”

“What was his mag potassium this morning?”

“K was 3.2, Mag 1.6 and replacement was not administered. It looks like he received his scheduled HCTZ and lasix this morning and has voided approximately 2.5 liters since 0700 today.”

“Draw a STAT BMP, give 40 mEq PO potassium x 1 dose and a mag rider of 2 gm IV x 1 dose. Call me back if his K is less than 3.0”

“There are no labs ordered for tomorrow. Do you want a BMP in the am as well?”


“Great. And his heart rate?”

“I don’t care.”

“How low can his heart rate get before you want to be notified?”

“As long as he’s asymptomatic, I don’t care.”

“K thanks bye!”

“GRrrrrr…” (grumble, grumble) (hangs up)

Orders you would enter:


BMP in am

magnesium sulfate 2 gm IV x 1 dose now

40 mEq potassium PO x 1 dose now

Call if K+ is less than 3.0

Call with symptomatic bradycardia, do not notify for asymptomatic bradycardia

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