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help me prioritize please

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by direw0lf direw0lf, BSN (Member) Member Nurse

direw0lf has <1 years experience as a BSN.

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Hey guys

I am having a hard time. I'm in a new grad program where I rotate to different units first before my placement. I rotated in pediatrics and MICU and now am in a neuro/tele step down. I thought this would be easy compared to the specialty units, but I have more patients and I'm falling behind. The PCAs are not taking my patients' vital signs or BS or cleaning them if they have a BM or transferring them from bed to chair or feeding (I feel better doing the transferring and though), etc. I am doing all that but this week I had a discharge and admission and I fell behind in meds. When I have blood sugars and see the food trays arrived and I'm stuck cleaning poop I don't know what to do. The PCAs haven't been helping me I think because they see we're 2 nurses here. But I'm in my 2nd week and doing the full assignment myself now, my preceptor checks my charting.

Anyway, could you all give me tips or advice please about prioritization? for example the other day at work:

1. Had AM BSs and insulin to give. So I pulled everyones meds, and since everyone was a BS, I didn't know if I should have given all the meds to each patient, or just went around for the BSs first then gone back to do the rest of the meds. 3 of my patients had PEG tubes for food/meds so that takes me a little longer crushing them and stuff. So what I did was give the insulin first then went back and did regular meds. Is that what you all would have done? 

2. by the time I was done with morning meds, it was 11:30, BS time again. I took that long because I also did my physical assessments, set people up to eat, transferred , mouth care etc.

3. At noon, wound care arrived and wanted my help with setting up a wound vacc, then the pt pooped, so I was in there for a while

4. one of my patients was getting d/c so I was giving report and getting that ready then another patient had a BP med issue I ended up calling the resident 4 times, bc the BP meds he kept giving would lower her HR and she was off tele and pharmacy I checked said she couldn't be

5. meds again, pt cleaning up, transferring, and I finally did my shift assessments, I was also behind in my q4h neuro checks now

6. Admission from ICU, had to change a person's room because this admission was a climber and she was being put in a room I couldn't have her in because too far from nurses station

7. Dinner trays came, I hadnt done BSs yet, more BMs had happened

 

ok that was about it what can I do different please?

 

edit - ok I read this over and it sounds like I'm complaining or something. Really I just want help to not fall behind any advice? TIA

Edited by direw0lf

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Seaofclouds is a BSN, RN and specializes in CCRN.

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What are the responsibilities of the PCAs on that floor? Do they obtain the BS's before meals? Sounds like some of the tasks could have been delegated to your PCA and that may be something you need to work on/address. Did you ask your preceptor their thoughts on how you handled your day? 

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Sour Lemon has 9 years experience.

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32 minutes ago, direw0lf said:

Hey guys

I am having a hard time. I'm in a new grad program where I rotate to different units first before my placement. I rotated in pediatrics and MICU and now am in a neuro/tele step down. I thought this would be easy compared to the specialty units, but I have more patients and I'm falling behind. The PCAs are not taking my patients' vital signs or BS or cleaning them if they have a BM or transferring them from bed to chair or feeding (I feel better doing the transferring and though), etc. I am doing all that but this week I had a discharge and admission and I fell behind in meds. When I have blood sugars and see the food trays arrived and I'm stuck cleaning poop I don't know what to do. The PCAs haven't been helping me I think because they see we're 2 nurses here. But I'm in my 2nd week and doing the full assignment myself now, my preceptor checks my charting.

Anyway, could you all give me tips or advice please about prioritization? for example the other day at work:

1. Had AM BSs and insulin to give. So I pulled everyones meds, and since everyone was a BS, I didn't know if I should have given all the meds to each patient, or just went around for the BSs first then gone back to do the rest of the meds. 3 of my patients had PEG tubes for food/meds so that takes me a little longer crushing them and stuff. So what I did was give the insulin first then went back and did regular meds. Is that what you all would have done? 

2. by the time I was done with morning meds, it was 11:30, BS time again. I took that long because I also did my physical assessments, set people up to eat, transferred , mouth care etc.

3. At noon, wound care arrived and wanted my help with setting up a wound vacc, then the pt pooped, so I was in there for a while

4. one of my patients was getting d/c so I was giving report and getting that ready then another patient had a BP med issue I ended up calling the resident 4 times, bc the BP meds he kept giving would lower her HR and she was off tele and pharmacy I checked said she couldn't be

5. meds again, pt cleaning up, transferring, and I finally did my shift assessments, I was also behind in my q4h neuro checks now

6. Admission from ICU, had to change a person's room because this admission was a climber and she was being put in a room I couldn't have her in because too far from nurses station

7. Dinner trays came, I hadnt done BSs yet, more BMs had happened

 

ok that was about it what can I do different please?

 

edit - ok I read this over and it sounds like I'm complaining or something. Really I just want help to not fall behind any advice? TIA

That sounds very simplified. I'm sure there are 1000 other things that happened that you're not mentioning. You've just got to figure something out that works for you.
Regarding accuchecks, I prefer to go do them all at once then come back around with medications, including insulins. Where I work, CNAs cannot check blood sugars.
I also assess on my first round, even though I may not chart until later.
I pull meds for one patient at a time, too. Pulling them for everyone at the same time is just asking for it ...and it really doesn't speed things up much, if at all.

Time and experience are your friends. You'll get there ...or as close to there are you can get. If your CNAs are not supportive or your job is not well-staffed, it may not be possible to be as efficient as you would like to be. 

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direw0lf has <1 years experience as a BSN.

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11 minutes ago, Seaofclouds said:

What are the responsibilities of the PCAs on that floor? Do they obtain the BS's before meals? Sounds like some of the tasks could have been delegated to your PCA and that may be something you need to work on/address. Did you ask your preceptor their thoughts on how you handled your day? 

Thanks for your reply! My preceptor and the other nurses tell me I'm doing fine.. I am my preceptor's first preceptee. She did add after that particular day this week that I need to show more confidence.

The PCAs responsibilities are to take vital signs, blood sugars, and assist in ADLs but if they can't get to something it's the nurse responsibility. I guess I feel uncomfortable asking for their help, but I need them.

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direw0lf has <1 years experience as a BSN.

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1 minute ago, Sour Lemon said:

That sounds very simplified. I'm sure there are 1000 other things that happened that you're not mentioning. You've just got to figure something out that works for you.
Regarding accuchecks, I prefer to go do them all at once then come back around with medications, including insulins. Where I work, CNAs cannot check blood sugars.
I also assess on my first round, even though I may not chart until later.
I pull meds for one patient at a time, too. Pulling them for everyone at the same time is just asking for it ...and it really doesn't speed things up much, if at all.

Time and experience are your friends. You'll get there ...or as close to there are you can get. If your CNAs are not supportive or your job is not well-staffed, it may not be possible to be as efficient as you would like to be. 

This is good advice about meds, thank you! I liked assessing before I even pulled meds on the other units I was on, but this one is just more patients per nurse, and true 1000 things I didn't mention happen in the day lol.

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AceOfHearts<3 specializes in Critical care.

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You need to get comfortable delegating or you aren’t going to make it. You can be nice, but you need to be clear and firm. 

When I worked the floor I found it helpful to almost explain my delegation- “Please help Mrs. White in room 3 to the bathroom while I check Mr. Brown’s blood pressure and give him pain meds.”

Yes, all of the things the aides do fall under your job title too, but there are many things YOU do that they can’t. Their job is to do what they can to keep the nurse free for tasks only the nurse can complete. That’s not to say that you never get a blood sugar or help with ADLs, but your priority is on assessing the patients, chart and lab reviews, meds, discussing plan of care with the patient and doctors, etc.

It sounds to me that the aides are taking advantage of you being new. You aren’t the first new nurse they’ll have seen. 

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34 minutes ago, direw0lf said:

Thanks for your reply! My preceptor and the other nurses tell me I'm doing fine.. I am my preceptor's first preceptee. She did add after that particular day this week that I need to show more confidence.

I don't prefer the orientation style you describe in your OP at all.

I don't know how long you have in each unit; I guess that probably has something to do with it.

Where is your preceptor while you're taking care of patients?

It is not acceptable for her not to be in and around the area. Her main job isn't to check your charting - part of it is to help you with these very things you're posting about. I would never think a new grad was struggling if they couldn't prioritize a full load 2 weeks in.

Hmmm. Honestly I would advise having a low-key sort of "I've been reviewing what I'm learning, and I wondered if...." chat with her, and just flat out ask if she can hang close so you can learn from her with regard to prioritization. That will also help if she's there as you're learning to delegate.

You'll get the hang of it. But if you're not working closely, try to see if you can facilitate that a little bit.

Good luck! 👍🏽

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direw0lf has <1 years experience as a BSN.

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6 minutes ago, JKL33 said:

I don't prefer the orientation style you describe in your OP at all.

I don't know how long you have in each unit; I guess that probably has something to do with it.

Where is your preceptor while you're taking care of patients?

It is not acceptable for her not to be in and around the area. Her main job isn't to check your charting - part of it is to help you with these very things you're posting about. I would never think a new grad was struggling if they couldn't prioritize a full load 2 weeks in.

Hmmm. Honestly I would advise having a low-key sort of "I've been reviewing what I'm learning, and I wondered if...." chat with her, and just flat out ask if she can hang close so you can learn from her with regard to prioritization. That will also help if she's there as you're learning to delegate.

You'll get the hang of it. But if you're not working closely, try to see if you can facilitate that a little bit.

Good luck! 👍🏽

Hey thanks for replying! I get 3 weeks in each unit, but some in the residency have only gotten 2 units but stayed in them longer. Even though that's the case, the units I were on before seemed very different, where I learned and got comfortable with skills, but not so much in time management. I like your idea to talk to her about staying by me for the help with prioritization, that's what I'm going to do next work day.

 

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nznurse93 has 2 years experience as a BSN.

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It comes with time. You will soon learn that you can’t do everything, and sometimes you need to hand something over to the next shift, or ask for help or give a med late. 

With the PCAs you need to be firm, I’m going to assume you young. Because the same thing happen to me as a new grad. The saw me as young new nurse and wasn’t that helpful, they were usually twice my age and had been working for many many years. You’re  in charge of delegating then task, so be firm. And always thank them, makes a big difference when they see you actually appreciate them. 

You also need to ask for help from other nurses. You should be working as a team. This includes the nurse co ordinating the shift, let them know when your really struggling. They are there to Help you too. 

Give it time. You will get there. You will learn what’s important and what you can put off/do late. 

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Been there,done that has 33 years experience as a ASN, RN.

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Where is you preceptor ? You should be working as a team, with her observing and stepping in when necessary.

The PCA's cannot call the shots as to which nurse they assist. Give them firm direction at the start of the shift.

Think about this, you are doing primary care while trying to learn. Speak with your preceptor stat to develop a better orientation plan. If it doesn't improve... go to nursing education.

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FolksBtrippin is a BSN, RN and specializes in Psychiatry, Pediatrics, Public Health.

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I think delegation is your issue, not prioritization.

In some work environments, it is very hard to get the PCAs to do their jobs. You might find out that this is what is happening. But you won't find out until you start  assigning them tasks. 

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NICUmiiki has 4 years experience as a BSN, RN and specializes in NICU/PICU Flight Nursing.

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Are you going up to them and asking them to do specific things and they are telling you no? Sometimes I feel frustrated when I feel that a tech is slacking, but I wouldn't complain until I've asked them to do it and they ignored me. Usually, asking directly fixes it without it going any further.

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