How can I improve?

Ruby Vee, BSN · Mar 23, 2017

Hello,
During our conference in clinical, I gave a report about my patients using SBAR. When I was finished my instructor asked me "What are your plans for each patient?" Man I was stumped! Usually I pick teaching, but that wasn't the highest priority this time. I didn't know what to say. How do I get better at this? Are there any books that help? I have a nursing diagnosis book but my patients have been having so many comorbidities I just can't seem to focus on what is the main priority.
For example, one patient had CHF (EF
How do you know what to focus on? I'm on a cardiac telemetry unit for clinical so the majority of my patients have a lot going on, and I don't seem to know how to prioritize and make goals.
Thank you for any help!
P.S. I do have a good knowledge of disease process I think...I mean I get A's in class. It's so different when I'm in clinical! Knowing for example CHF patho, s/s, dx studies, and treatment facts is one thing, then having a patient with it and it's very individual, that's a whole other thing, and I'm not good at it..

While you were correct about skin care being an issue for your patient, it wasn't going to kill her this week. When you're working in acute care, your priority is going to be what brought them to the hospital and/or what's most likely to compromise them now. Skin care is always a concern, but your first priority is not letting your patient die on your shift. So what things are going on with her that could lead to problems NOW? The protein/albumin issue could be one of them. Electrolytes are a huge concern, especially if she's vomiting them all out. Think airway/breathing/circulation first. A man with a big MI is fluid overloaded and is getting diuretics, but hasn't got any potassium checks ordered. His K+ drops and he has arrhythmias. Your renal/cardiac patient may not tolerate dialysis because her albumin is low -- why would that be? What special problems does she have that are contributing to the low albumin? The PICC and albumin replacement will help, but how do they help? If anemia is a problem, is her hematocrit low enough that you need to worry about her having another MI because there aren't enough red cells to carry oxygen to the myocardium?

I think we all struggle with this prioritization thing at first, and then with some experience, you have a much clearer idea of the priorities. If you understand the pathophysiology, you can figure it out rather than just guess. So the key is understanding the pathophysiology and knowing which things are most unstable right this minute, over the next few hours, today or this week. Those are your priorities.