As others have mentioned, it depends on thye nursing environment in which you work. I have worked only in ICU and emergency, so I can tell you some of the things I do and general points about what I chart:
In emergency, tasks include:
-taking patient history (before the ER physician sees them)
-assessing routine vital signs (respiratory rate, blood oxygen conc. (SpO2), temp, BP, heart rate)
-assessing visual acuity (e.g. for patients who have chemical spills in their eyes)
-initiating standard protocols (treatment algorithms) for patients with chest pain, difficulty breathing, etc. before a physician sees the patient
-performing CPR, chemical or electrical cardioversion, and countershock
-administering drugs and monitoring patients during "conscious sedation" for uncomfortable or painful procedures (giving e.g. fentanyl and propofol while the doc reduces a hip joint)
-washing ("hosing down") patients -- some of whom haven't been near a shower in weeks :->
-calming suicidal/homicidal/violent patients
-preserving evidence (chain of custody) in criminal (esp. r**e/homicide/suicide) cases ...
-A,B,Cs (airway, breathing, circulation), Ds (Dsability, e.g. GCS, LOC, pupils, focal neurological deficits (sensory and motor)), Drugs, Es (Exposure -- taking (or cutting) clothes off) -- physicians determine F (Fix or flight (i.e. to OR direct))
-initial assessment, time of arrival, physical charactaristics pertinent to the chief complaint, and all the procedures you perform and drugs you give. Depending on the drug, vitals pre- and post- administration; writing *impressions* of ECGs (we do not make medical diagnoses) and alerting physicians to such things as lethal dysrhythmias, ST-elevations/depressions, etc.
-drawing venous or arterial blood samples
-interpreting arterial blood gas (ABG) reports
-Recording ventilator settings (RRTs and dos make *most* of these adjustments -- our job is to alert the healthcare team to problems with vent. settings, e.g. if a patient is not tolerating a particular mode of ventilation), listening to lungs, ensuring placement of endotracheal tube (ETT), sampling and analyzing arterial blood gas samples (ABGs)
-Recording and analyzing ECG (12-lead or 5-lead trace interpretation)
-Head-to-toe asssessment (most patients in the ICU I work in are unconscious and ventilator dependent, so going through all the systems: CNS, CV, RESP, GI, GI, and Integumentary) is important
-Mouth care: suctioning, swabbing gums (to prevent ventilator associated pneumonia (VAP))
-Continuously monitoring physical parameters (usually more invasive than in emergency), e.g. intracranial pressure (ICP), cerebral perfusion pressure (CPP) for patients with external ventricular drains), arterial blood pressure, central venous pressure (CVP), left ventricular end-diastolic pressure (LVEDP) for PTs with pulmonary artery catheters (aka Swan Ganz catheters).
-Performing ACLS (basically advanced CPR with drugs)
-Removing and troubleshooting invasive monitoring devices (EVDs, art lines, femoral sheaths, etc.)
-Testing the level of paralysis (using a "train of four" stimulator) for chemically paralyzed patients
-Bed baths, mobilization, general nursing care, e.g. provision of scheduled drugs, PRN meds (e.g. to keep systolic BP around a certain target, or to deal with "tube tolerance," and pain)
-Making sure your 'christmas tree' (IV pumps and lines) are organized and always 'ready to go' if the patient happens to need a STAT CT or another test ('trip')
-Rounds: giving report in morning and evening sign-out rounds .... e.g. how has the patient been doing generally; what does the patient do when the sedation 'lightened,' min/max heart rate, ectopic complexes (on ECG), BP range during shift, drugs given, CSF drainage, urine outputs ... whatever is pertinent to the patient and his/her particular clinical condition.
-Mixing IV drip solutions (e.g. insulin, narcotics, pressors, etc.)
-Safety checks (vent. alarm settings, bagger at head of bed, monitor alarm settings)
-Complete head-to-toe assessment (tick charting + narrative charting)
-Making note of special proceures, e.g. off unit with patient for an angiogram, aneurysm/AVM/DVF embolization, CT, MRI, etc.)
-Recording hourly measurements of all pertinent physical parameters (tick charting)
... *lots* more, but that is a pretty accurate description of what I do and chart in these different environments.
Answered By: Aiden - 2/22/2008