How to prioritize 4+ patients?

[xmilkncookiesx]

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.

[xmilkncookiesx, RN]

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.

[Captain_k]

Honestly, when I was going through that in school, I remember it being terribly overwhelming. But it was the prep that was overwhelming! Not the Actual shift. It made for so many hours put in in a dAy. However, we were so prepared, and our shifts went so well.

Also, our instructors selected our patients carefully for us. They made sure the meds they were on (and number of meds) and conditions they had were appropriate to help us learn. And they were there with us all day every day.

I feel a little sad for you that you aren't being properly supported.

My instructors would always say that we didn't have to feel nervous for our evaluations, because if there was an issue, we would know long before our evaluation came. So it's really unfair that you were surprised by bad critiques during your evaluation.

You can do it though! It will get easier and easier. I feel bad that you are not getting more support though. I don't think it's your fault at all.

[edmst]

.....

[edmst]

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!

You are already encouraging bad habits to a nursing student that he/she may carry into their nursing profession? No matter how thorough a report may have been, one must ALWAYS check the orders, labs, etc. to confirm and not take the previous nurse's word for it. Assessments on all assigned patients should be performed prior to lab draws/medication administration because the assigned patients that were taken report on are now your responsibility. To have multiple patients and give advice to take care of 1 patient at a time without doing an assessment on all their assigned patients is irresponsible. What if one of the other patients were crashing? Oh, but labs are pending for the other? Irresponsible.

[Lisacar130]

You told her that you are having a hard time managing 4 patients so that's why she gave you an N for managing 4 patients. I mean honestly nursing is very hard and even experienced nurses have a hard time doing it all. I learned in nursing school to look confident and calm when my teacher was looking, so that she would give me a good grade. Fake it. You are probably doing better than you think. Your teacher isn't the person to vent to if you think you are having a hard time managing 4 patients. Just do the best you can and act like you are more confident than you are. It does effect your grade.

[Castiela]

You are already encouraging bad habits to a nursing student that he/she may carry into their nursing profession? No matter how thorough a report may have been, one must ALWAYS check the orders, labs, etc. to confirm and not take the previous nurse's word for it. Assessments on all assigned patients should be performed prior to lab draws/medication administration because the assigned patients that were taken report on are now your responsibility. To have multiple patients and give advice to take care of 1 patient at a time without doing an assessment on all their assigned patients is irresponsible. What if one of the other patients were crashing? Oh, but labs are pending for the other? Irresponsible.

I disagree that it's unsafe to do assessments/ meds/vs on one patient at a time before moving on to the next. I've always done it that way and have yet to be surprised by a patient crashing. Generally report will give you an idea as to who is the sickest of your assignment, so you can prioritize that way. I also visualize eac of my patients before starting which gives me info on their ABCs. I honestly think it is a personal preference and you can do things either way.

Our workplace, there just wasn't time to check all the orders before that day started. The expectation was that the night shift had checked the orders and Mars and ensured everything was correct. As long as it was signed for, you could proceed without having to check it yourself.

[SouthpawRN]

I am surprised that you are in 4th semester and only just passing meds. Is this common in other programs? The program I am in, we were passing oral and topical meds 1st semester, IM, SQ G-tube meds second half of first semester, IV meds and drips second semester. we started with just one patient and had to have all the details of each med along with nursing considerations for them before giving them. So it took about an hr to document all the patients meds in the beginning. Starting with 3 or more patients for passing med seems crazy. What did you do the first 3 semesters if you were not allowed to pass meds? In 4th semester, we are in critical care doing pretty much everything...

I would try and make a list of the common meds on your floor, ask the nurse to just name the common meds of the top of her head. you are going to get the ones given most often that way. really learn those and then you only will have to look up the less common meds. I have a list of probably 50-60 meds that my patients were getting the first 2 semesters. (realistically, the program should have had you looking up and learning about all the patient meds starting first semester, even if you were not giving them)

[SouthpawRN]

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!

I think that the challenge here is that nursing instructors want students to do a complete head to toe on each patient. whereas in reality, you are doing focused assessments initially, which indicates if you need a more in-depth assessment of something. Therefore, what the professors want are not always realistic IMHO. we definitely looked at everything as far as admission notes, labs etc, but when we had time for that which is usually later in the morning or early afternoon.

[TriciaJ, RN]

I'm a bit surprised that a student is managing 4 patients. When I worked med-surg and precepted students, no one would ever take more than one. They all insisted they could take two after they had mastered working with one, but they never did. Time-management never stopped being a huge issue no matter how I tried to present it. I rarely saw an instructor; I would arrive at work and be informed I had a student and that was it. And the students were from several different schools in the area, not just one.

I often wondered how those students made out when they hit the real world. Had to have been difficult. My point is, OP, just keep doing your best and I'm impressed that you're working so hard and requesting feedback. When you are orienting to your first job, you won't have half the struggle in store for many of your peers. Just keep on keepin' on.

[NICUismylife, ADN, BSN, RN]

You are already encouraging bad habits to a nursing student that he/she may carry into their nursing profession? No matter how thorough a report may have been, one must ALWAYS check the orders, labs, etc. to confirm and not take the previous nurse's word for it. Assessments on all assigned patients should be performed prior to lab draws/medication administration because the assigned patients that were taken report on are now your responsibility. To have multiple patients and give advice to take care of 1 patient at a time without doing an assessment on all their assigned patients is irresponsible. What if one of the other patients were crashing? Oh, but labs are pending for the other? Irresponsible.

When I get morning report, it is done on a WOW (workstation on wheels) at the bedside. All orders and labs are reviewed on the computer together, as well as the IV site and all drips being double-checked together. All of this is signed off on by both nurses, also on the computer. Therefore, I have also laid eyes and hands on every patient prior to the shift beginning and am well aware of whether one of my patients is unstable or "crashing."

But way to make assumptions.