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What do nurses do?

thenextchemist

When I did some work experience in the outpatients department, I was working with two nurses at the reception.

They had the most boringest job ever. All they did was call out patient and do the regular checkup and then go back and sit at reception.

I worked at the hospital for about 2 weeks and it was the same old process.

I don't know if they were proper qualified nurses like with a degree or anything but I'm so sure a nurses job is better than that and more demanding, a lot more fun and there's more activity involved I guess.

Can anyone tell me more about this because I'm certain this isn't the job that nurses do and there's much more intensity involved,

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Reply 1

PaediatricStN

Original post by Bloom77

Outpatient department nursing probably isn't the best place to get a good idea of what nurses do!

I'm just gunna go through and do a massive list of the sorts of things nurses do/situations we encounter/things I/my colleagues are responsible for on the ward where I work. (I work on a large, busy medical ward in a children's hospital). In no particular order, here we go... Some of the terms I don't expect you to understand, so Google them! :smile:

Observations (A-E assessment, Heart rate, temperature etc), neurological observations, enteral feeds, total parental nutrition, administering all medications, blood glucose/ketone monitoring, taking blood samples, pain assessment and management, chest drain management, oxygen therapy, management of peripheral and central venous access devices (Cannulas, central lines etc), management of a tracheostomy, management of a naso pharyngeal airway, management of a patient's hydration status, seizure management, personal care tasks, tissue viability management... Within that you have a responsibility to escalate anything you are concerned about. I've used the term "Management of" alot to simplify and shorten what I'm saying :smile:

Those are very much "Clinical" tasks, but there is also a lot of liasing with other professionals, hospitals and sometimes referrals to be done. As a children's nurse safeguarding is a massive part of my job and some shifts I can easily spend up to an hour in total speaking to all the other professionals involved in the care of a child we have safeguarding concerns about.

Also, another big part of my job is to communicate with and reassure the parents/families of the children I look after.

All of the above has to be documented one way or another and this takes time too. Hospitals all have slightly different sets of paperwork but the principles of documentation are the same, and they are all legal documents.

And somewhere among all of that, you're supposed to take your breaks and leave on time! Hope that gives you more of an insight into what we do.

What I do is quite broad because of the area i work in, others who work in more specialised areas will do slightly different things.

Reply 2

thenextchemist

Original post by PaediatricStN

Thank you so much!v
This was extremely detailed!! I loved that !!

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Reply 3

ButterflyRN

I agree with PaedietricSTN, outpatients clinics are definitely not the best area to work in to get an idea of what nurses do on a daily basis!

I work on an acute medicine of the elderly ward and here are a few things I do on a daily basis:

-Washing patients and assessing their skin integrity and providing pressure area care. This can include repositioning the patient, mobilising the patients, applying barrier creams etc.

-Assessing patients mobility. We get most of our patients out of bed for breakfast so we assess how they walk/transfer and assess what manual handling equipment is the best to use, then refer to physiotherapy and occupational therapy as needed.

-Assessing nutrition and hydration and feeding patients. This not only includes monitoring what the patient is taking orally but how they are managing. Some may have swallowing difficulties so may require referrals to SALT to ensure their diet and fluids are at a safe consistency and may need dietician referrals for poor dietary intake. They may need calorie shots are nutrition drinks, milkshakes and yoghurts.

-Administering medication. Elderly patients are usually on a crap ton of meds so it's important you know what they are all for and what side effects to watch out for and to watch out for any contraindications. Elderly patients are also notoriously difficult to get meds down so it requires a great deal of skill and persuasion to get them to take their meds. And a lot of patience.

-Monitoring continence/elimination. It's very important that we monitor if our patients are passing urine well and properly. If they have increased frequency they may have an infection or may be in urinary retention. We can get urine dips to test for infection and then send them off for analysis. If they are in retention we can scan their bladder to see how much urine they are retaining and insert a catheter if needed. Monitoring bowels is also important. If they are constipated then that can cause urinary retention so we may need to give enemas and laxatives. Also monitoring for diarrhoea is important and get a sample early is important. Antibiotics can cause c-difficile which is a hospital acquired infection that hospitals can get fined for. We also get patients who have stoma bags. A stoma is a hole in the abdomen from the intestine area that excretes faeces. We have to monitor these closely to ensure they are active and not too loose. They tend to be a lot looser than normal poo, but we have to make sure that they don't lose too much fluid otherwise the patient can dehydrate.

-Monitoring fluid balance. It's important that enough fluid is going in, but that enough is coming out. If a patient isn't passing much urine and they aren't retaining urine then it's possible they are in kidney failure or acute kidney injury which means they need a lot of hydration to get their kidneys to work properly. Equally you don't want too much coming out either as that can also damage that kidneys and dehydrate them.

-Catheter care. Again monitoring output, colour of urine and ensuring there is no blood, clots or pus in the urine. Also ensuring that the catheter site is clean and that the bags are changed regularly. If the catheter is beginning to clog up and block we can give a bladder washout. This is just squeezing a bit of solution through the catheter to unblock it and ensuring it drains back properly. If it doesn't then we sometimes need to insert a new catheter. Some urinary catheters are not inserted into the urethra (pee tube) but directly into the bladder through the lower abdomen. These are called suprapubic catheters.

-Administering IV medication. We administer a lot of intravenous fluids, antibiotics, blood and drugs. We have to be mindful of the effects these drugs can have on the elderly. If an elderly patient has heart failure then we can't give too much IV fluid because excess fluid builds up on the chest and can make them very poorly, very quickly.

-Administering injections. We also get to administer a lot of intra muscular and sub cutaneous injections. The most common subcut injection is enoxaparin which prevents patients from developing blood clots whilst in hospital. We also administer a lot of subcut injections for patients who require end of life medications such as morphine for pain, and medications to manage agitation, nausea and respiratory secretions.

-Syringe drivers. Some patients who are receiving palliative care may need continuous infusions of painkillers or medicines to stop them from getting agitated, feeling nauseous and preventing respiratory secretions etc. This is a little pump that administers the medication over 24 hours. We have to check it every so often to ensure it's running properly, has enough battery power and has not been tampered with. This syringe is locked away in a case so only people who have the key can touch the syringe.

-Subcutanous lines/infusions. A bit like managing a peripheral cannula and IV infusion but usually these infusions run much more slowly as the fluid can build up under the skin. The same principles apply looking after a subcut line as a peripheral cannula.

-Enteral feeding. If a patient is unable to swallow, or have a condition where they require feeding via an NG tube then we can administer medication and feed via this tube. NG tubes can be very dangerous as if they are not in the correct place you can feed directly onto the lungs, so it's important you test the ph of the tube to ensure the tube is in the tip of the stomach and not the lungs. We also get patients with NJ (nasal tube that goes directly into the small intestine), PEJ (tube that goes straight into the small intestine inserted through the abdomen), RIG and PEG tubes (tubes that go straight into the stomach inserted through the abdomen). They all require different types of care. I can also insert NG tubes but not all adult nurses are able to as you have to gain extra competencies to do this.

-Managing peripheral cannulas and central access devices. Managing a cannula is slightly different to a CVAD device. Any nurse who is IV trained can use peripheral cannulas but you have to go on extra training to be competent to look after a CVAD. It's not difficult but requires extra care and attention than a cannula.

-Wound care. The elderly come in with all sorts of gory and funky wounds. Some will have horrendous pressure ulcers, some will have horrendous leg ulcers. Others will have very delicate skin that tears easily which requires dressing and some of them will come in with bruising and cuts from falling. We even get to remove stitches and staples from time to time but not very often. We get to assess and clean these wounds and apply the appropriate dressings.

-End of life care. Some of our patients will come to the end of their life. When this happens we provide the patients with comfort care, help them with diet and fluid as and when they want it, make sure their mouth is clean and moist if they can't take anything orally and keep them comfortable, free of pain, distress and agitation. We keep them comfortable and carry out any last wishes they and the family have. I find that when I am caring for end of life patients I am caring more for the relatives than the actual patient because it's such a distressing and difficult time. You need to have a lot of compassion, patience, empathy and understanding.

-Oxygen management. Some patients will require oxygen for their medical conditions. It's important to monitor their saturation levels. Some elderly patients will have chronic breathing conditions which means that if they get too much oxygen it can be damaging for them so we have to be mindful not to give them too much sometimes and expect their saturation levels to be lower.

-Monitoring observations and early warning scores. We monitor blood pressures, pulse, temperatures, respiratory rates, oxygen levels and consciousness score. We have to monitor what is normal and abnormal because this can indicate certain complications such as sepsis, heart attack, internal bleeding, stroke, respiratory failure etc. We also check blood sugars for diabetic patients and patients who are on steroids to make sure their blood sugars are in normal range. We have to act on these as needed to ensure the patient gets the correct management and treatments.

-Neurological observations. We get a lot of patients who have fallen and hit their heads. We closely monitor their consciousness and use the Glasgow Coma Score, test their eyes are equal and reacting and monitor their limb movement. We have to be careful of brain injury. We also do this for patients who are having seizures.

-Management of fractures. We get a lot of patients who will have fractured various bones from falling as their bones will be very brittle. We tend to get a lot of broken wrists and arms and occasionally legs. These patients go to fracture clinic to get their bones plastered or splinted. We have to make sure we do exercises and monitor the plaster sites as the arms and legs can swell once the plaster goes on which can be dangerous and cut off the blood supply to the limbs.

-Referrals. We do a lot of referrals to other agencies such as physiotherapy, occupational therapy, mental health liaison, IMCA, SALT, dieticians, diabetes specialist nurse, respiratory specialist nurse, tissue viability, heart failure nurses, social services, continuing healthcare, DOLS, district nurses etc.

-Looking after relatives. A lot of time the relatives are more difficult to look after than the patients. They are often worried and concerned and don't understand what is going on so you have to explain things clearly, have empathy and compassion and patience. Most relatives are pleasant and although they can appear intense at first, they generally calm down once you've explained what's going on and they understand what is happening. Others can be damn right rude and nasty. I've had relatives screaming in my face for absolutely no reason, had some threaten to report the ward to the papers and I have even come across some filming staff, documentation and things happening on the ward. The daily mail has a lot to answer for.

-Care planning and risk assessments. You must ensure that you risk assess on transfer, weekly or as the patients condition changes. There are multiple assessments to complete such as falls, moving and handling, tissue viability, nutrition, usage of bedrails and other bits and pieces. We have to make sure our care plans are tailored and written according to our patients needs and must be updated at least once per shift. I write the bulk of my care plans in the morning, then comment on any changes in the afternoon or if the patient is settled with no issues I will say so.

-Dementia care and diversional therapy. Many of our patients have dementia which means they can be challenging to look after. They already have a cognitive illness which means they are usually confused and disorientated but when they come into hospital they have a medical illness on top and are in unfamiliar surroundings which makes it twice as difficult to look after them and manage their behaviour. We often invite relatives to come in so they recognise a familiar faces, get their relatives to bring in items they can relate to which we can also use as distraction (e.g ask them about who is in the picture, what was happening in that time etc). We also cohort our confused, high falls risk patients in the same bay where 1 staff member is present at all times to ensure the patients are safe and that someone is there if they need to get up or want something etc. We try to do activities with our patients but do not always have the time, but we are going to knock out our MDT room soon to make sure our day room is at the top of the ward and appoint an activities co-ordinator who will go around and do activities with the patients, active and bedbound patients and liaise with relatives to ensure really good patient centred care. We always have old music playing as the patients really enjoy it and helps calm them down. We also refer to psychiatry if a patient is particularly difficult to manage. We try to veer away from sedation but sometimes the patient can get so distressed and only use it if all other forms of management has been tried and failed.

-Last offices. When a patient has passed away there are certain duties a nurse must carry out. We must document any medical devices left in the patient and any necessary medical information. We then go and wash the body and prepare it for the mortuary. Every nurse has their own way of doing it. I tend to open the window for a while, as there is a myth that when a patient dies their soul needs to leave the body. I also talk to my patient as if they were alive when I am washing them, as they are still a person and a patient in my care. I think last offices is one of the most privileged duties you can perform on a patient, albeit a sad one.

We don't get an awful lot of airway or tracheal management on our ward like PaediatricSTN does. Occasionally we insert a naso-pharyngeal airway if a patients GCS drops and the tracheostomys tend to go to the respiratory wards, although we do get them from time to time. Any other patients that requires airway management will tend to go to ICU where they can be ventilated if necessary. We don't get too many drains either but again we do sometimes. We tend to get pleural drains to drain off excess fluid in heart failure patients and I have known liver and ascitic drains too. We even had a rocket drain once, that was interesting.

We treat a whole variety of conditions such as UTI's, pneumonia, cellulitis, infected wounds, osteomyelitis, heart failure, seizures, falls, fractured bones, GI bleeds, cancer, sepsis, heart attacks, renal failure, respiratory failure, strokes, bleeds on the brain, meningitis, encephalitis, intestinal blockages, retention, uncontrolled diabetes, constipation and a whole heap of other things.

We look after all sorts of different illnesses. Care of the elderly certainly isn't boring and I come across new things every day! It's not just confused ladies wanting to go home, or wiping bums, cleaning up poo and social sorts. It's actually very, very interesting and very, very busy! And believe it or not, we actually have a very high turnover of patients and our length of stay isn't that much longer than any of the other medical wards and specialities.

(edited 7 years ago)

Reply 4

PaediatricStN

@ButterflyRN Really detailed post, very interesting to read the differences between paediatric and adult medicine. (Though I'm still very firmly a paeds nurse!)

We probably do more airway management than you due to the number of admissions due to respiratory reasons (Bronch, croup, pneumonia etc) and the fact that a lot of paediatric hospitals don't have respiratory wards as there isn't such a clinical need for it - we are the respiratory ward for our hospital! (As well as the metabolic ward, neurology overflow ward, gastro ward and any other strange condition that doesn't fit one of the specialty wards we do have!!!!)

OP, I realised I overlooked something in my answer... I said what a nurse in my sort of ward does on a day to day basis, but that isn't necessarily what all nurses do.

There are many nurse specialist and nurse practitioner roles available, who will take on advanced roles such as assessment, reviewing and prescribing. Many will have their own patient caseload and be autonomously responsible for this.

There are roles within nursing management, both locally and nationally, who will be responsible for recruitment, retention, policy, service developmenta and all sorts of other stuff I probably am blissfully unaware of.

On top of this there are jobs within nurse education - both as a clinical educator on a ward focussing on staff development and as an academic based within Higher Education Institutions.

So we've given what a nurse atypically does, but there is way more to even that!

(edited 7 years ago)

Reply 5

ButterflyRN

Original post by PaediatricStN

I find it interesting to read about the different branches too. Not only different branches, but different specialities in the same branch of nursing! We get respiratory conditions but we don't tend to get patients that need specific monitoring and airway management. We don't do NIV either so they have to go to one of the respiratory wards. I think that respiratory conditions in children tend to be far more acute and can deteriorate very, very quickly. The elderly can deteriorate quickly, but breathing conditions in children is a different kettle of fish.

Our DME ward is basically a dumping ground for elderly patients that no other speciality really wants to look after. So we literally get everything. Orthopaedics and cardiology are notorious for this (at least in my hospital) even if the complaint is specifically an orthopaedic or cardiology problem! We had a patient admitted with an external fixator the other day. None of us have ever looked after an external fixator in our nursing careers. It was an orthopaedic problem but because the patient was old we ended up with the lady! Thankfully the ex fix is off now, but orthopaedics have been less than helpful. Gynaecology are quite precious about who gets their beds too. My lady with the rocket drain was a gynaecology outlier. Of course, none of us had ever even heard of a rocket drain before haha! I do like how varied DME is though, we learn a little bit about a lot of things!

My new job is going to be totally different than the ward work I do now! I am going to work on the Frail and Elderly Assessment Team which is based in A&E and MAU. My job role is to identify and assess patients who meet the FEAT pathway criteria. My main job will be to prevent admissions for FEAT patients who are medically fit but need physio/OT and social sort. I will be able to arrange emergency care packages, rehab at home, rehab and respite. My role is also to ensure that the patients get the right assessments in a timely manner. If they do need to be admitted because they are unwell, my role will be to ensure they do get some sort of FEAT assessment whether it's by me or the OT/physio as it helps the base ward know what the patient is normally like and what they need. I can also ensure that they go to the correct ward and make sure they receive a Comprehensive Geriatric Assessment. My role will probably include more bits and pieces but will mainly involve assessing, referring and arguing with the ED/MAU co-ordinator :P So again, this is one of the other roles nurses can do :smile: