Cold Sassy

Day 1- I arrived @ 6:40am and formally introduced myself to my preceptor, Courtney Phelps. We received shift report from the three nurses we would be receiving patients from, and then went to see our patients. We introduced ourselves and she did her morning assessments, and wrote on their boards. She then orientated me to 5East, showing me the supply room, medication room, dirty linen room, and break room. She then sat down to the desk to organize her day using this "cheat sheet" she uses to jot down all the things she has to do for the day. We then went to gather up meds, and she showed me how to use the caremobile. After giving meds, we went back to the desk and she showed me how to chart. She explained the importance of charting and how clients are assigned and how point are accumulated. She explained the because this is a stroke floor that we have neuro checks q 2 hours the first 48 hours and q 4 hours thereafter for all stoke patients. We documents the four P's(pain, potty, position, and I can't remember what the last p is called but it is if call light within reach) q 2 hours on every patient and assess twice a shift. Day one I mostly assisted, learned the routine, and scanned the meds. He is on Telemetry.

Day 2- I did all the same things as Day 1 but on day two I received two patients of my own which I took the lead on. The first was RG a 48 year old male that suffered a stroke. He is a total care patient, completely flaccid on the right side. He was on a mechanical soft diet and has to be feed. He does take his pills whole two pills at a time @ 0800, 1200, and 1700. He is turned q 2 hours. He has a 22g in his right AC. He is receiving 0.9NS @ 75mL/hr and Rocephin 2g in 50mL of 0.9 NS. He receives neuro checks q 4 hours. He has a 16Fr Foley Cather in. He has been on her since 12/13/10 and is awaiting Medicaid for placement in a nursing home. I changed all his IV tubing when administering meds and assisted with his bath. I also did all of his charting with the assistance of my preceptor. My 2nd patient is DC a 39 year old male suffering my different problems due to hemorrhagic stroke. He has a history of smoking, alcohol, and cocaine abuse. He was admitted 1/14/11. He has a history of noncompliance with his hypertension meds. He is a total care patient completely flaccid on the right side, but uses a urinal with assistance. He has a PEG tube in. His speech is kind of gargled. He has been running a low grade fever