How to prioritize 4+ patients?

  1. Hi. I am in nursing school, my last semester (4th).

    Right now in clinicals, we are assigned to 3 patients but help the nurse manage 4 patients. All we have been doing is med pass and assessments, and charting head-to-toe assessments on 2 out of the 3 patients.

    My clinical instructor has barely talked to me during clinicals since she's on another floor with other students or I'm always in a procedure or she is passing meds with another student. This week was the FIRST time I was able to pass meds with my professor (and then we can finally pass meds with our nurse). This is our 5TH WEEK already. So for 4 weeks, she didn't pass meds with me but she did with everyone else and she was aware of it.

    She gave us our clinical feedback this week individually and I have some N's (Needs Improvement). But I am confused because the other 4 weeks, all she did with me was come see me for 3min or so and ask about my patients and I gave a brief report to her, and said what type of meds they are on, and how they currently are doing. And she kept saying I am going great and that it sounds like I have everything worked out.

    But when reviewing my feedback, I have N's on "managing 4 patients" and "knowing medications". How can she grade me on these when she JUST passed meds with me THIS week? And she doesn't know my struggle with managing 4 patients UNTIL I told her THIS week since she never had time for me previously.

    Every time she came around 4 weeks ago, she would just ask if I have the meds ready and I would say no because I JUST got back from procedure and just began to look into them. And she would say okay thats no problem.

    So that really upset me because she said after this week, the N's will matter if we get a lot.

    I do struggle handling 4 patients. and ESPECIALLY if they have SO many damn medications. omg idk how to manage it all. its so overwhelming.

    Here is what I do when I come into clinical:

    get report from nurse
    look at admission notes
    look at labs
    look at meds (I write them down first and TRY to review them all before seeing my patients but it takes FOREVER because some I have never heard or seen or don't remember. Pharm was horrible for my class).
    then I go in to see my patients, do my assessment on them
    get vitals
    then I go to try and review the medications and THATS when my clinical instructor pops up.


    She told my clinical group that we are all doing VERY good, and that the other clinical groups instructor is struggling with their students, that they are doing poorly. I even told her I struggle with getting all of the pt info down first before seeing them. and all she said was, "yea you have to figure it out." you know, I'd like some guidance instead of figuring it out myself. I asked my nurses and they said they all struggle still, and they told me their routine and I tried each of theirs and I still struggle.

    Can someone please help me? I am usually on a cardiac unit, whether its med-surg/tele unit.
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  2. 21 Comments

  3. by   brownbook
    I may be wrong. It does sound unfair. But teachers evaluating students, (and supervisors evaluating staff), are told to NOT evaluate too highly, because then they can't show the person improved on the next evaluation.

    My first evaluation of an excellent medical unit clerk I gave all high marks and a very positive written evaluation. My boss looked at it before I gave it to the clerk and said, "You can't give all high marks, then you won't be able to show they improved next time".

    Just maybe let it pass and keep up your good work. If the next evaluation is the same you should calmly ask for clarification.
  4. by   xmilkncookiesx
    Quote from brownbook
    I may be wrong. It does sound unfair. But teachers evaluating students, (and supervisors evaluating staff), are told to NOT evaluate too highly, because then they can't show the person improved on the next evaluation.

    My first evaluation of an excellent medical unit clerk I gave all high marks and a very positive written evaluation. My boss looked at it before I gave it to the clerk and said, "You can't give all high marks, then you won't be able to show they improved next time".

    Just maybe let it pass and keep up your good work. If the next evaluation is the same you should calmly ask for clarification.
    Thanks! She said these past few weeks, the N’s didn’t matter but these next upcoming weeks (3 weeks because we have 8 week courses) the N’s WILL matter.

    But how do you manage this patient load? What is best to do first? I feel like she was annoyed that I wasn’t prepared. But we were never taught how to manage this load. I need some sort of guidance, time management skills, prioritization with 4 patients.
  5. by   Castiela
    With 4 patients, I read the kardex, look at labs then do a quick visual of all my patients. If everyone is stable I will see patients in priority of the perceived sickest/ actively crawling out of beds, those who need to have tests/ go to OR. I tend to do my vital signs, assessment then med pass for each patient before going to the next (this is just the flow I like, everyone has their own style). Usually that will take me to 0900 which is break. Afterwards, I will check for new orders, wash patients, mobilize, chart etc. I tend to make a quick note in my cheat sheet re: any abnormal assessment data I come across as I tend to have the memory of a gold fish and keep 4 pts assessments straight., which makes my charting easier later on.

    There is no right way, just what feels comfortable, you will get faster/ more comfortable with more experience.

    Can you do medication review the night before or make flash cards for meds you commonly see? I have nursing central on my phone and just use that to review medications I'm not 100% familiar with. I tend to just look at mechanisms of actions, side effects and what I need to monitor for when I give the medication. It's nice to know the mechanism of action, and other information but I don't find I need that information right then. That could save you some time in the am
  6. by   xmilkncookiesx
    Quote from Castiela
    With 4 patients, I read the kardex, look at labs then do a quick visual of all my patients. If everyone is stable I will see patients in priority of the perceived sickest/ actively crawling out of beds, those who need to have tests/ go to OR. I tend to do my vital signs, assessment then med pass for each patient before going to the next (this is just the flow I like, everyone has their own style). Usually that will take me to 0900 which is break. Afterwards, I will check for new orders, wash patients, mobilize, chart etc. I tend to make a quick note in my cheat sheet re: any abnormal assessment data I come across as I tend to have the memory of a gold fish and keep 4 pts assessments straight., which makes my charting easier later on.

    There is no right way, just what feels comfortable, you will get faster/ more comfortable with more experience.

    Can you do medication review the night before or make flash cards for meds you commonly see? I have nursing central on my phone and just use that to review medications I'm not 100% familiar with. I tend to just look at mechanisms of actions, side effects and what I need to monitor for when I give the medication. It's nice to know the mechanism of action, and other information but I don't find I need that information right then. That could save you some time in the am
    Thank you. And no we can’t look at the meds the night before. We aren’t given pt info until morning of. But I go home and review the meds I’ve written down
  7. by   Castiela
    Do you find that you're becoming more familiar with common meds? Our pharmacy class was essentially self taught so I can empathize with struggling to memorize everything ^_^
  8. by   NICUismylife
    How are the morning reports that you are getting? If you are getting a thorough report, you shouldn't have to review admission notes and labs, they should have already been included in morning report, and if it's not, then ask! I rarely get a chance to review admission notes or H&P until later in the shift. Get report, maybe glance at the labs and meds to plan out your schedule for the day (0800 meds vs. 1000 meds, etc), and then go straight in and get your assessments in ASAP. I'm like the pp that said they try to finish each patient before moving to the next. For example, if I have a patient that has labs right off, then I'll normally do their assessment and labs first prior to heading to the next patient. Or if I have one that needs meds right off, then I'll do their assessment and meds first before moving to the next.

    A good brain worksheet is essential, IMO. If your school doesn't provide one, then I suggest you make one up for yourself. I would be a disorganized mess without mine!
  9. by   NICUismylife
    Also, once you've been on a particular floor for a while, you will notice that there are some meds that are super common. When I was in school, I kept a one-page log of them that included indication, mechanism of action, safe dosage, administration info (slow push over 2 mins vs. 60 min IVPB, etc), common side effects, most severe side effects, contraindications, and preparation. It saved me so much time from having to look up the same meds every shift.

    For example, I had famotidine, pantoprazole, furosemide, spirinolactone, heparin, enoxaparin, warfarin, prednisone, ondansetron, morphine, dilaudid, lisinopril, hydralazine, metformin, insulin, cephazolin, etc.
  10. by   JBMmom
    I agree that getting the most useful information at report and prioritizing based on that will be key. I come in for third shift, so it's slightly different because some of my patients are (theoretically) sleeping. If you have a complete handoff report, you shouldn't need to do much research, if any, before seeing your patients. I am personally not as concerned with what a note/lab/computer charting says, as I am with putting my eyes, ears and stethoscope on the patient. I would estimate that report is usually done between 11:30 and 11:40pm. By 12:30am, I've usually seen everyone, in order of most critical to least, and I've done my safety check- name and date of birth compared with bracelet, checked what's hooked up to the patient- IV, O2, Foley, etc., and asked if they are having any pain. It doesn't always work out that way because if patient's number 2, 3 and 4 all need pain meds, now we're past 1am before I've seen the others.

    Use your available resources. If you're lucky enough to take report on all your patients from one nurse, ask them- based on this assignment, how would your prioritize my next steps? Everyone was a student at one point, and everyone was a new nurse. There's no problem with asking a question to help you learn the best approach and any nurse should be willing to spend a minute to go over the assignment quickly for prioritizing. After you've seen everyone, then you read the notes, labs, etc. If you see a sodium level of 126, you might be very concerned, but if you've been in and spoken with your patient and there no complaints of weakness, fatigue, headache, muscle cramps, etc- that's might not be out of the person's baseline. Also, many people will share with you important information like "my sodium always runs low because I drink a lot of water", during an initial conversation.

    It will all come with time, don't worry too much, you sound like you're very much on the right track. And meds will come with time, you'll start seeing some of them over and over and will not need as much work there. Good luck!
  11. by   Captain_k
    When I was in school, we were expected to go in the night before or an hour early on the first day with a new patient load. We were expected to review the chart, make a care plan, and have detailed med information ready for every med we would be giving.

    We were never allowed to give a medication without knowing what it was for first.

    There is no way you can review charts and meds before your shift starts and have med cArds ready? As a student, you should have med cards with you.

    Also I never review notes and labs on a patient before doing assessments. I would use the information from report. I would review the careplan, then go down and do vs and an assessment on each patient. Then pass meds. Then you can sit down and chart later and review the chart a bit more at that time.
  12. by   xmilkncookiesx
    Quote from Castiela
    Do you find that you're becoming more familiar with common meds? Our pharmacy class was essentially self taught so I can empathize with struggling to memorize everything ^_^
    Ours was self taught. she taught us based off her experience as a nurse, not the books we bought. so it was definitely hard and especially because no anatomy and physiology review was provided before going straight into the medications .. which they NOW understand why we struggled with pharm.
  13. by   xmilkncookiesx
    Quote from JBMmom
    I agree that getting the most useful information at report and prioritizing based on that will be key. I come in for third shift, so it's slightly different because some of my patients are (theoretically) sleeping. If you have a complete handoff report, you shouldn't need to do much research, if any, before seeing your patients. I am personally not as concerned with what a note/lab/computer charting says, as I am with putting my eyes, ears and stethoscope on the patient. I would estimate that report is usually done between 11:30 and 11:40pm. By 12:30am, I've usually seen everyone, in order of most critical to least, and I've done my safety check- name and date of birth compared with bracelet, checked what's hooked up to the patient- IV, O2, Foley, etc., and asked if they are having any pain. It doesn't always work out that way because if patient's number 2, 3 and 4 all need pain meds, now we're past 1am before I've seen the others.

    Use your available resources. If you're lucky enough to take report on all your patients from one nurse, ask them- based on this assignment, how would your prioritize my next steps? Everyone was a student at one point, and everyone was a new nurse. There's no problem with asking a question to help you learn the best approach and any nurse should be willing to spend a minute to go over the assignment quickly for prioritizing. After you've seen everyone, then you read the notes, labs, etc. If you see a sodium level of 126, you might be very concerned, but if you've been in and spoken with your patient and there no complaints of weakness, fatigue, headache, muscle cramps, etc- that's might not be out of the person's baseline. Also, many people will share with you important information like "my sodium always runs low because I drink a lot of water", during an initial conversation.

    It will all come with time, don't worry too much, you sound like you're very much on the right track. And meds will come with time, you'll start seeing some of them over and over and will not need as much work there. Good luck!
    Thank you, this has given me some relief!
  14. by   xmilkncookiesx
    Quote from Captain_k
    When I was in school, we were expected to go in the night before or an hour early on the first day with a new patient load. We were expected to review the chart, make a care plan, and have detailed med information ready for every med we would be giving.

    We were never allowed to give a medication without knowing what it was for first.

    There is no way you can review charts and meds before your shift starts and have med cArds ready? As a student, you should have med cards with you.

    Also I never review notes and labs on a patient before doing assessments. I would use the information from report. I would review the careplan, then go down and do vs and an assessment on each patient. Then pass meds. Then you can sit down and chart later and review the chart a bit more at that time.
    First semester we were able to have the whole pt info the night before. But we haven't in the last few semesters. But this semester is really complicated for me since its a big load for me and some of my pt have SO MANY MEDS, I mean its SO frustrating.

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