Learning to balance multiple patients

I posted this in response to a students question on the forums. This is kinda what my day is like. I also have an awesome report sheet 'brain' that I adapted to fit my needs. If you want a copy PM me your email address and I will give you one.

1st - go in and get my patient load (a charge nurse schedules the load for each of the nurses)

2nd - go listen to report

3rd - go through the meds I will be giving for the shift keep track of said meds on my cheat sheet AKA Brains

4th - Go in order of room number/necessity and assess each patient. I assess head to toe. Lungs, Heart stomach (listen to), assess if the patient is alert and oriented to person (self) place, and time (date - or day of the week), Equal hand grips, equal pulses, Strength of each extremity (squeeze or push), check lines, check vitals and sats (in some cases neuro assessments - PERRLA, response to stimuli) There's alot more. Chart at each patients room.

5th - Give meds

6th - Chart vitals

7th - well basically at this point I either go through patients charts, call doctors with labs or whatever, and once this is done I try to spend some time with my patient.

8th - Basically the Vitals are q4h, Meds can be every hour on up to 7-8 patients (not normally every hour on every patient, but out of that many patients usually at least one will have a med. And charting. Beyond that it's just a cycle.

Thank you very much for your response. That gives me a good idea of what to expect!

I was also concerned about having multiple pts as a new nurse. One good thing is that you don't have as much wasted "down" time when your pt is out of their room for a procedure or you need a certain piece of equipment- you can just move on to the next task/ next patient and come back to the first.

All things being equal, learn to cluster your tasks as much as possible (unless they're neuro patients, in which case you don't want to cause too much stress at a time.) Say you come in at 7pm, and two of your patients have 8pm meds, and the rest have 9pm meds. Go in and do your assessment on the 8pm med folks first, giving them their meds while your in there. By the time you get done there, it's close to time to give your 9pm meds, and you can give those while you assess those patients. If you know someone will be "talky" and time consuming, when possible, make them the last person on each round, so if you get stuck for a few extra minutes, you won't be behind with the other folks. And some people don't agree with this, but things don't have to be right on time. If it gets done, it gets done. People stress about getting a qDay dressing change done between 9pm and 11pm because it's scheduled for 10pm. If it goes 25 hours one day and 23 hours the next between changes, the world won't stop! Get it done when it's most convenient for the patient in that general time frame.

Just remember, it's tough now because you have to think about every little thing. Charting will soon become automatic, knowing what the meds are will be automatic. Instead of every little thing being a chore, you'll be done before you know it!

I kind of wonder about the multiple patients thing, too. I have enough trouble handling two. I was wondering what things are priorities. For example, I had a PICC dressing change that needed to be done, the patient had continuous bladder irrigation, so his bags and foley needed to be changed constantly, patient was receiving blood, etc. I felt that the blood and the foley stuff took priority, and the nurse I was working with said the PICC dressing was a bigger priority than the foley and irrigation bags. Once I thought about it I saw "Yes, PICC=Circulation, and ABC's are the most important" but I couldn't see it by myself. They were out of dressing kits, so my instructor had ordered some, but four hours later they still weren't there. I hadn't been able to think far enough ahead to think "Hey, I could improvise with a clear dressing", and when my instructor pointed that out, I was "Duh! That's SOOO obvious". Well, I hope it just means I'm learning and not that I'm a complete idiot! :imbar

I kind of wonder about the multiple patients thing, too. I have enough trouble handling two. I was wondering what things are priorities. For example, I had a PICC dressing change that needed to be done, the patient had continuous bladder irrigation, so his bags and foley needed to be changed constantly, patient was receiving blood, etc. I felt that the blood and the foley stuff took priority, and the nurse I was working with said the PICC dressing was a bigger priority than the foley and irrigation bags. Once I thought about it I saw "Yes, PICC=Circulation, and ABC's are the most important" but I couldn't see it by myself. They were out of dressing kits, so my instructor had ordered some, but four hours later they still weren't there. I hadn't been able to think far enough ahead to think "Hey, I could improvise with a clear dressing", and when my instructor pointed that out, I was "Duh! That's SOOO obvious". Well, I hope it just means I'm learning and not that I'm a complete idiot! :imbar

a simple dressing change on a picc before irrigation bags on a 3 way??

imo, the irrigation continuing without a lot of interuption is pretty important. i wouldn't want the foley to clot off.

case in point, the whole day went by without the dsg getting changed right? now, imagine if you let the 3 way go all day without changing bags etc??

think of things like this:

if i don't get to it in 30 minutes what will happen? those things come first.

blood administration is VERY HIGH priority. i always stay with my pts for the first 15 minutes.

I can fully relate to mulitple pt loads Im in my second year out as RN wking on busy ortho ward which is a 30 bed unit of critical/trauma PTs. we get 5-6 pts each but because the hospital is so over full we are getting alot of outlie pts from different wards. this makes it extremely hard to keep on top of our work load particually when we are not familair with the nursing care for the pt if has nothing to do with bones. I have certainly learnt to pioritize my wk load. Pt safety comes first and if that means I have to miss a shower or sponge because I spend 20 mins finding out what to put on a 3rd degree burn by ringing the burns unit in my ortho unit that is what I do. those RNs who come on after me may have a maon becuase I didnt get through all my wk load oops might have missed a ECG that nedds to be done for the next day. but at least I go home satisfied that I did the best I could with my hours I had and that sometimes means missing out on lunch breaks.

This is my routine in a nutshell: Get report, then pop in and introduce myself to each patient. Next gather all charts and review the orders and progress notes. Then start to assess patients and pass meds. After that chart, diagnose rythym strips, etc. After patients are settled for the night I'll carefully read each H&P and review progress notes again. At the same time I'm making notes for shift-change report. Of course, the routine can vary at times depending on shifting priorities. Eventually, with time, your organizational skills and efficiency improves. Good luck.

I am 3 weeks away from graduating right now, and believe it or not, you absolutely will be able to take care of multiple patients. As other replies have said, you will get better with experience and things become more automatic. Nursing school is stressful and intimidating, and I finally came to a point where I realized that making mistakes, although scary, is part of the learning process. Nobody's perfect, and it was really hard for me to deal with this in nursing, because let's face it, we are dealing with people's lives.

You will be pushed beyond your comfort zone when your instructor gives you more patients, but you will get through it and become a better nurse. Any decent clinical instructor, is able to guage what the student can and can't handle, and will only give you what you are capable of (it's their license on the line!!) And with each stressful day, you can leave the floor, and reflect on what worked for you, and what you could do better, and come back with more knowledge.

That being said, my routine is similar to others:

Come in, (as a student, I already have my assignments)

Eyeball my patients, make sure they are breathing and not falling OOB.

Get report, check meds and blood sugars.

Consolidate: try to do vitals and assessment together

After getting a picture of what i'm dealing with, plan my day from there.

Realize that my plan most likely will get disrupted, and accomodate as needed.

think of things like this:

if i don't get to it in 30 minutes what will happen? those things come first.

That is great advice! Thanks. It's funny, but when you're new to something it's hard to gauge how accurate your intuition is. I have a good sense of what a priority is when it comes to the ABC's, but after that it gets muddy. This advice makes perfect sense to me.