A day in the life of a band 5 staff nurse – Medical and Surgical Mixed Ward.
06.30 -Left the house with my daughter still sleeping. Luckily at 7 years old she can understand that she won’t see me until before school tomorrow morning.
07.00 -handover time on the ward. There’s 18 patients currently on the ward and we take vital information from the night duty nurses regarding how the patients are responding to their treatment and what their plan of care is. We also have a quick safety briefing regarding those patients who are at risk of falls, not for resuscitation (receiving end of life care), on high risk medication such as morphine (as we need to look out for side effects like respiratory depression or increased drowsiness). We are expecting 4 new admissions and I am asked to admit 1 of them when they arrive at about 11.00 hours – they are due to have surgery this afternoon.
The workload is delegated out by the nurse in charge and I am responsible and accountable today for the care of 6 patients (plus my new admission). I have one patient with dementia waiting for discharge to a nursing home, 2 post-operative patients (patients who had surgery yesterday) requiring regular observations, medication and wound care, 1 patient undergoing investigations for abdominal pain, 1 patient who is at the end of life who is needing regular turns and medication administration and one patient with a severe infection of the leg called cellulitis.
07.40 Before I start I delegate a couple of tasks to the HCA (health care assistant) who is working with me. I ask them to assist the dementia patient with breakfast and then to encourage them to have a shower. We then need to work together to provide care to our palliative patient.
07.45 My medication round starts with my first patient who can’t manage to eat any breakfast as they are still feeling nauseous after anaesthetic. I need to draw up Intravenous (I/V) medication so go and find another registered nurse as all IV’s have to be to double checked with 2 nurses. My patient has pain but feels too sick to take anything orally. I relay this to the nurse in charge who telephone’s the ‘on call’ consultant to come in and prescribe an IV. I make the patient as comfortable as possible and let them know the doctor is coming as soon as he can and to call me if the anti-sickness medication results in them feeling well enough to take oral analgesia (pain killing medication).
I move to my next patient who is the patient with cellulitis. The red area that was marked out yesterday by the nurse is now bigger. They have been on the prescribed antibiotics for 48 hours now so I wonder if it’s the right treatment. I give them some pain medication and say I will return later once they have worked as I have to bandage their legs to contain the fluid oozing from them. I pass on my concerns to the nurse in charge as not only are the patient’s legs more inflamed but their temperature is rising and already high heart rate is increasing which could be an indication of the infection getting worse - I am concerned. It seems as though the infection isn’t under control just yet.
My dementia patient has had breakfast and I give them medication and stay until they swallow them. I need to keep reorienting their surroundings as they are very confused . The patient is very agitated this morning and tends to wander when they are like this so I ask my HCA to stay close as the patient is quite unsteady and a falls risk.
My other post op patient seems to be doing ok other than feeling a bit ‘spaced out’ after their operation. I give them routine analgesia (pain medication) etc and go to my next patient.
My next patient is the one with abdominal pain. The patient came in overnight and is ‘nil by mouth’ at the moment. They are in a lot of pain and I decide that analgesia is essential and give them the smallest sip of water I possibly can – just enough so to can swallow the medication. They have a scan booked for 14.15 so apart from monitoring their vital signs and ensuring the pain is controlled, there’s not much I’m needed for at this time. I explain the importance of being ‘nil by mouth’ – because of the possibility of urgent surgery.
The patient requiring end of life care is currently sleeping and isn’t due any oral medication, only a syringe driver (medication delivered by a drip) which will need changing at approx. 10.00am. The family are also due in about 10.30 hours and we will aim to have the patient washed and bed changed before then, so we don’t have to disturb them.
08.45 My HCA colleague has showered our dementia patient and is sat with them doing a puzzle to keep them occupied until the family arrive. This is extremely important as they may fall over if left to wander.
My nauseous post-operative patient doesn’t want to get up at the moment so I make sure they are comfortable and let them rest. They promise to ring the bell when they are ready to get out of bed for the first time. It is important they do this supervised because they may be dizzy and also we can advise them of the most comfortable way to move post-operatively.
I help the 2nd post-operative patient to get to the bathroom, and place them on a chair with towels and wash bag within reach. I advise them not to rush but to ring the bell when then have finished so that a nurse can help them back to their chair/bed.
The patient with cellulitis is happy to shower themself and knows the routine and where everything is.
The patient with abdominal pain is independent with their own hygiene needs so once I have disconnected them from the IV fluids they can go and have a shower. They will use the call bell when finished and I will reconnect the IV fluids up. Their legs will then be redressed.
09.30 I commence washing the palliative care patient and call for some assistance when I’ve got to a point where I need help to roll the patient onto their side and change the bed sheets. The patient is very drowsy but winces when I begin to roll them which is an indication that more analgesia is needed to keep them comfortable. I need to draw up and check an extra dose of morphine with another registered member of staff. It’s the second dose needed this morning so I ask the nurse in charge to let the consultant know the patient requires a review of the analgesia in the syringe pump. The nurse in charge contacts the doctor to come up to the ward. I inspect all of the patient’s pressure areas when washing and see that there is a slight redness on the heels so apply a couple of heel dressings that are padded and should limit the amount of marking. The patient’s mouth is very dry so I gently apply mouth care, and make sure they are comfortable before the family arrive. They usually stay most of the day and like to help out with the care. This is an important part of our nursing day but it is difficult to find enough time.
10.00- Time for routine observations of my patient’s vital signs (vital signs are observations of temperature, blood pressure, pulse, respirations (breathing rate) and oxygen levels). I need to record almost all my patients apart from my end of life patient, and the patient with dementia who only requires twice daily observations – the first was done at 6am and isn’t due again until 6pm.
10.15 Time to attend to my palliative care patients’ syringe driver. I draw up the medication with another registered nurse and set the pump running over 24 hours. I need to check this is running and effective every 4 hours.
My post-operative 1 patient has just vomited and I give them another anti-sickness medication dose through the I/V. I measure the amount of fluid they have vomited and write down the amount on their fluid balance chart, which is negative at the moment. Their observations are showing a low blood pressure and high pulse. I feel because of their dark urine and negative fluid balance that they are probably dehydrated, so phone the doctor who can’t get to the ward for a couple of hours because she’s in clinic. She organises an email prescription for some more I/V fluids to be given and promises she will come up to see them as soon as she can. When the prescription arrives via e-mail, I check the I/V fluids with another nurse and explain to the patient that it is to treat dehydration . This patient has no cardiac problems but sometimes we need to watch for things like fluid overload in patients. I’ll recheck their obs in an hour.
My 2nd post op patient’s obs appear to be within normal limits, just a slightly low BP which is not unusual in patients who have had an anaesthetic. I’ll recheck that in an hour and see how they are.
My cellulitis patient’s temp isn’t as high now. They believe the shower helped and is feeling better. The paracetamol I gave appears to be working. Their heart rate is still higher than I would like but their consultant has just come to the ward and is about to review them so I just mention it to the nurse in charge.
My abdominal pain patient has a high blood pressure and pulse, probably due to pain so I give them some more analgesia and ask them to call if the pain doesn’t start to improve.
10.30 The family of my palliative care patient arrive. The patient’s daughter is upset by the deterioration and I take her into the office for some privacy and explain what our plan of care is. I make the family a fresh tray of tea and ask them to call me if they need anything. I offer to call the hospital chaplain but they decline this at this time.
11.00 A patient arrives on the ward and is due to have surgery on the afternoon list. I need to do the paperwork. I show the patient to their bed and explain what is going to happen. I ask my HCA to check our patients and to go for a quick 10-minute break – enough time for a cuppa and quick snack. Unfortunately, I haven’t had time for one yet this morning, but I manage to go into the staff room to eat a banana, and that will keep me going until lunch time.
I do a quick check on my post-operative patient 2 to check their BP is stable and am pleased to see that it is improving. I’ll recheck at 12 noon. Post op 1 patient is now feeling better. Their BP is also stabilising.
My new patient has come in for a laparoscopic cholecystectomy (keyhole surgery to remove the gall bladder). I assess their care needs and write some care plans around this. I ensure that they haven’t eaten anything since midnight and I work with my HCA to get them prepped for theatre. I make sure they understand the procedure and explains what will happen afterwards. I also complete a falls risk assessment which we have to do for everyone over the age of 70, as well as patients deemed at risk of falls. This in itself takes me 20 minutes, and the total documentation for a surgical patient is around an hour in total.
12.00 Medication round again
This is always a quicker round as its mostly just analgesia but I notice that my cellulitis patient has been started on a different I/V antibiotic so I draw this up with another nurse and give it to them. I explain to the patient what it is and finally finish the medication round and put my trolley away. My colleague is helping patients with lunch.
12.30 I update everyone’s fluid balance charts to record their input/output for the day
12.40 Lunch. I manage to take a full lunch break as the ward is settled. I’m link nurse for infection prevention so pick up a couple of emails on my break from the specialist nurse asking me to pass on some information to the ward manager and other colleagues. I also have an email to tell me that my blood transfusion e-learning is due for renewal – I’ll hopefully get 5 hours back for doing this in my own time but it’ll have to be a quiet day and I know full well it will take me at least 8 hours to complete!
13.10 I do my final bits of theatre preparation for my patient due surgery this afternoon and just recheck my post operative 2’s observations again. Their blood pressure is within normal limits now which means I can now move them to routine 4 hourly obs. My cellulitis patient’s legs have been bandaged by another nurse as they were wet with fluid from them. I thank her for helping me – we are a good team and help each other when time allows.
Post op 1 is feeling less nauseated and wishes to get up for a wash so I help them out of bed and ask them to use the call bell when needed. They later call and I help them to the chair. They feel much better for having a wash and sitting out.
13.30 I take my patient to theatre and hand over vital information: checking identity, consent form and information about when they last ate and drank and medical history etc.
13.50 Back on the ward and it is time to start my 2pm obs. All my patients are doing ok apart from my cellulitis patient whose temperature has risen again. They are able to have some more paracetamol now and I also get a fan for comfort. Hopefully the new antibiotics will begin to work in the next 24 hours or so.
I do my syringe driver checks and am satisfied that everything seems to be effective as when I turn my palliative patient onto their other side to relieve the pressure there is no sign of distress. Their breathing is becoming shallower so I mention it to the nurse in charge who ensures that the family are aware of this further deterioration and that it is a sign that the patient might pass away in the next few hours. They want to call in other members of their family so I show them to the office to enable them to do this in private.
15.00 I start writing up all my documentation from this morning. This is really important so that I can evidence the care I’ve given to my patients. This includes any instructions from the doctor’s round, any changes to treatment, how effective it is, anything I’ve escalated as a concern and an evaluation of my patients’ care plans.
15.45 I am called to collect my patient from theatre. They are awake and comfortable. They have I/V fluids up but the operation went well and they require routine post-operative observations.
16.00 Post op obs start. ½ hourly for 2 hours then hourly for 4 hours. I need to check all vital signs and to check their wound for any signs of bleeding.
17.00 Dinner arrives
I need to give my post-operative patient 1 some more anti-sickness medication for their nausea and check to see if my abdominal pain patient is now allowed to eat and drink following their scan. I discover that the Consultant plans to take them to theatre at 1830 for emergency surgery so they must remain nil by mouth. I will need to ensure that a surgical check list is undertaken.
My HCA colleague is assisting our dementia patient with dinner. I go around updating everyone’s fluid balance charts.
18.00 My colleague offers to help out with the routine observations while I do the syringe driver check and fluid balances. Then hopefully we can go for a quick meal break – or at least a cuppa in the office. When I check on my palliative care patient, I notice that their breathing has become slow and shallow and I inform the family that they have deteriorated further and it is likely that they will pass away soon. I ask if they would like a nurse to sit with them, but they decline. I decide not to turn the patient onto their other side at this point so that their family can sit with them without being disturbed. I inform the nurse in charge of the deterioration and we agree to ensure that the patient is checked every 5 minutes.
18.15 and I start my 1800 drug round slightly late. Amongst other drugs I need to give a dose of warfarin which is a blood thinning drug so I need to check the patient’s blood results before I give it as too much could cause a bleed. I need to give 3 lots of different I/V antibiotics. This takes quite a while to draw up and administer and all have to be checked by another nurse.
18.45 A family member tells me that they think their loved one has passed away. I go and check and agree. I offer the family my condolences and explain that the nurse in charge has to undertake the full verification of death. The family wish to stay a while longer and I close the door of the patient’s room to allow them some privacy to say goodbye. They leave the ward at 19.15 and before they leave I ensure they know that they can telephone us if they have any questions over the next few days. They thanked the staff for their support over the past few months.
19.00 I continue to do my post-operative observations. My patient hasn’t yet passed urine - I need to ensure they are creating urine within 6 hours of surgery so will pass on to the night staff that they may need to scan their bladder at 21.45. When my HCA colleague returns from his tea break I ask if he would like to assist me with providing last offices for our patient who has died. He has helped with this once before and understands what is required.
19.45 Myself and my HCA colleague undertake last offices for our patient, there is never a time I don’t feel emotional doing this- especially when I could see how upset the family were leaving. The patient had been well known to us for several years and we have got to know the family well.
20.30 I write up my notes and care plans from the afternoon part of my shift and handover to the night staff. I am pleased to see them!
21.30 I arrive home, have a shower and put my feet up with a cuppa. My daughter is already asleep, and it’ll not be long before I am!