New RN needing prioritization advice

Susie2310 · Apr 10, 2018

On one of my first days of orientation, my preceptor asked me which pt I thought I would see first. I chose the most acute/urgent needing pt and was told that instead I should see the pt that I thought I would be able to address the fastest first, and choose the pt with the most time consuming tasks for last. This makes sense in order to get more done on time, but is the opposite of what we were taught.

If you leave your most unstable, acutely ill, patient till last, there is a good chance they will be deteriorating during the time they are waiting for your care, while you are seeing patients in the order that meets YOUR time management needs best. Your most unstable, sickest patient, should be seen first. Nursing care is centered on the patient, not the nurse. If you have a patient with sepsis/severe sepsis, acute renal failure, and other co-morbidities, are you going to prioritize them last because they will require more time than other less sick patients? Having been the family member of a patient with severe sepsis who apparently was prioritized last, and whose admitting nurse found it more important to ask non-essential admission risk assessment questions than notice that there were no orders and go about obtaining orders asap while my family member used up their last bit of strength fighting for their life answering inane questions about suicidal thoughts, I strongly urge you to put patient needs ahead of nurse convenience. Prompt treatment can mean the difference between life and death or permanent organ damage for some patients.

Susie2310 · Apr 10, 2018

Coming in and getting hit first thing in the morning with a list of things I didn't do the night before messes with my head for the rest of the day causing me to doubt myself. No one is rude or unprofessional, mind you. I just feel that telling me at the end of the day before I leave when you find these things is more psychologically manageable for me than having the next charge nurse told about it in the morning and having her tell me.
Thanks in advance!

I suggest asking the charge nurse for clarification on what items you are expected to complete by the end of your shift.

Susie2310 · Apr 10, 2018

If you leave your most unstable, acutely ill, patient till last, there is a good chance they will be deteriorating during the time they are waiting for your care, while you are seeing patients in the order that meets YOUR time management needs best. Your most unstable, sickest patient, should be seen first. Nursing care is centered on the patient, not the nurse. If you have a patient with sepsis/severe sepsis, acute renal failure, and other co-morbidities, are you going to prioritize them last because they will require more time than other less sick patients? Having been the family member of a patient with severe sepsis who apparently was prioritized last, and whose admitting nurse found it more important to ask non-essential admission risk assessment questions than notice that there were no orders and go about obtaining orders asap while my family member used up their last bit of strength fighting for their life answering inane questions about suicidal thoughts, I strongly urge you to put patient needs ahead of nurse convenience. Prompt treatment can mean the difference between life and death or permanent organ damage for some patients.

I also want to suggest using ABC's to aid in your prioritization. For instance, you would prioritize an obstructed airway first, respiratory distress second, and circulatory problems third.

Susie2310 · Apr 10, 2018

So, my questions are: How do you keep track of all of the many things we need to do in a day and get to them when you have a full load of heavy patients. (For example, my patient load this weekend was a CHF pt requiring a hoyer to be moved with an NG on continous feeds who required all meds to be crushed and given per ng and was incontinent and on sunday we only had one tech all day, another pt with CHF exacerbation who had a long list of meds to give who I admitted an hour before shift change saturday night, another on TPN with C diff on contact precautions and a third who had a bedside thoracentesis sunday d/t recurring pleural effusion of autoimmune nature) and second, how do you manage the eat our young mentality of nursing as the newby and not get discouraged by it?
Thanks in advance!

How are you keeping track of everything you need to do? Are you using a brain sheet?

marienm, RN, CCRN · Apr 11, 2018

I hear you that getting a list of stuff you forgot first thing is demoralizing. Charitably, I'll assume that your charge nurse is trying to help you, either by letting you know so you can fix your charting, or at least letting you know so you don't become the nurse no one wants to pick up from!

What kinds of things are on that list? Is it 'unit maintenance' stuff like stocking your rooms with linen and a pile of periwipes? Every unit has tasks that certain shifts seem to be expected to do, and they're probably not on a checklist anywhere. They're also not critical, but you can bet other people will be annoyed if you routinely don't do them. Develop a pattern whereby you include this in your workflow.

Or is it stuff like missing medications or other treatments? Figure out why you are missing them...do you not know where to find the orders? Not sure which orders are still current? Medication wasn't delivered and you forgot to follow up? Just didn't have time? (In which case you should ask for help rather than skip things.)

Or is it patient-care stuff that you are supposed to know (but isn't going to be in an order)? Like, at my facility we change tube feed setups every 24 hours and IV tubing every 72. These are based on policies. When I don't know how often to change something, I look it up. If you need to change your tube feed, make a habit of looking at the date & time...do you need a new set-up or just a new feeding bag?

FWIW, I agree with your initial instinct to see your sickest patient first. However, by 'see' I mean look at them for a quick minute to make sure they are okay...don't necessarily do their whole bath and meds and whatever else. Do get a baseline of their ABCs and obviously attend to any immediate need.

zombie nurse, BSN, RN · Apr 11, 2018

If you leave your most unstable, acutely ill, patient till last, there is a good chance they will be deteriorating during the time they are waiting for your care, while you are seeing patients in the order that meets YOUR time management needs best. Your most unstable, sickest patient, should be seen first. Nursing care is centered on the patient, not the nurse. If you have a patient with sepsis/severe sepsis, acute renal failure, and other co-morbidities, are you going to prioritize them last because they will require more time than other less sick patients? Having been the family member of a patient with severe sepsis who apparently was prioritized last, and whose admitting nurse found it more important to ask non-essential admission risk assessment questions than notice that there were no orders and go about obtaining orders asap while my family member used up their last bit of strength fighting for their life answering inane questions about suicidal thoughts, I strongly urge you to put patient needs ahead of nurse convenience. Prompt treatment can mean the difference between life and death or permanent organ damage for some patients.

I am so sorry that happened! Just to clarify, I am certain my preceptor would not have me prioritize anyone over an unstable patient. Also, post procedure patients who require frequent assessments cannot be a lower priority.

Thanks!

zombie nurse, BSN, RN · Apr 11, 2018

How are you keeping track of everything you need to do? Are you using a brain sheet?

I am trying out different brain sheets, and in absence of a preprinted one, I use the list of patients they give me which has space between each name to make one up for myself. Orders I need to keep track of go on the left (Code status, I/O, fluid restrictions, etc) In the middle I write the scheduled meds, on the right I put things I need to pay attention to such as a need to get certain info from the family or something the night nurse passed on to me that I need to call the doctor for. I also write my IV rates on the right side and any procedures they are having that day.

zombie nurse, BSN, RN · Apr 11, 2018

I hear you that getting a list of stuff you forgot first thing is demoralizing. Charitably, I'll assume that your charge nurse is trying to help you, either by letting you know so you can fix your charting, or at least letting you know so you don't become the nurse no one wants to pick up from!
What kinds of things are on that list? Is it 'unit maintenance' stuff like stocking your rooms with linen and a pile of periwipes? Every unit has tasks that certain shifts seem to be expected to do, and they're probably not on a checklist anywhere. They're also not critical, but you can bet other people will be annoyed if you routinely don't do them. Develop a pattern whereby you include this in your workflow.
Or is it stuff like missing medications or other treatments? Figure out why you are missing them...do you not know where to find the orders? Not sure which orders are still current? Medication wasn't delivered and you forgot to follow up? Just didn't have time? (In which case you should ask for help rather than skip things.)
Or is it patient-care stuff that you are supposed to know (but isn't going to be in an order)? Like, at my facility we change tube feed setups every 24 hours and IV tubing every 72. These are based on policies. When I don't know how often to change something, I look it up. If you need to change your tube feed, make a habit of looking at the date & time...do you need a new set-up or just a new feeding bag?
FWIW, I agree with your initial instinct to see your sickest patient first. However, by 'see' I mean look at them for a quick minute to make sure they are okay...don't necessarily do their whole bath and meds and whatever else. Do get a baseline of their ABCs and obviously attend to any immediate need.

I agree that the list is just to help me. I don't know why it gets to me, except that it is first thing in the morning and the job is so intense that I already have to psych myself out to carry the necessary confidence for my patients sake. It is water under the bridge, but I didn't realize just how overwhelming this position would be for me as a new RN, and it may not have been the best choice for me. Experienced nurses who work on this floor say that they are tired of feeling like a failure for always being behind and feeling like they are drowning. It is a tough floor.

As for what ends up on the list, it varies. While not on the list, I was told by the nurse who took my patients Saturday night that I was supposed to change the NG tubing every 24 hours on continuous feeds, as I had not done so. Can you suggest other things like that I should look up for future reference?

This Sunday the list involved the fact that the admission was not completed Saturday night, that my 1800 meds were not given on two of my patients, and that I was there 1.5 hrs after shift ends.

When I worked in a different unit at the same hospital as an LPN, admissions were passed on to the next nurse to complete. Apparently, on this floor you are responsible to complete your own admission, unless they arrive within 15 minutes of shift change. So, the expectation was that I stay to complete it, but I did not know that. I told the next nurse what I had completed and what was left like I would have on the other unit. I ended up completing the admission the next day, and we have 24 hours to complete them, so it all worked out with this patient.

I did not give my 1800 meds because that is when the admission arrived. My charge nurse told me to ask another nurse to help me in the future, something I wasn't sure of with everyone so busy themselves. Sometimes we have a SWOT nurse who can help so I will try to find one next time.

SpankedInPittsburgh, DNP, RN · Apr 11, 2018

First, take a deep breath. Welcome to Nursing!!! Your first job reminds me of mine. I worked on a very busy surgical step down / high observation unit filled with all sorts of patients from fresh post-ops to ICU dumps who were simply going to die and it was apparently thought that their taking up an ICU bed was a waste. Nursing school prepares you to be able to get a job. Being on the unit makes you a nurse. Take in all criticism and learn what you can from it and improve your practice. Do not expect all nurses to agree on what should be done and when it should be done. For example, I'm an ER nurse now and this whole "leave the sickest patient for last" advice is contrary to just about every instinct I have. Know there is an element in nursing that loves being hyper-critical to other nurses especially those who aren't positioned to tell them to go pee up a rope. You jumped in the deep end of the pool quick and have a steep learning curve ahead of you so face that stark reality. My advice is to stick with it, do your best, do NOT personalize the job and simply learn. Know there are many good nurses who also happen to be good people and they will help you. Finally recognize that this is a job. When you leave work leave the job behind. You need to recharge and get ready for the next shift. I wish you luck!!!! We have all been there!!!

Susie2310 · Apr 11, 2018

I am trying out different brain sheets, and in absence of a preprinted one, I use the list of patients they give me which has space between each name to make one up for myself. Orders I need to keep track of go on the left (Code status, I/O, fluid restrictions, etc) In the middle I write the scheduled meds, on the right I put things I need to pay attention to such as a need to get certain info from the family or something the night nurse passed on to me that I need to call the doctor for. I also write my IV rates on the right side and any procedures they are having that day.

I think you are definitely on the right track by using a brain sheet. I think it takes time to find out what really works best for one. If you do a search for "brain sheets" in the search bar, you will find many brain sheets that members have posted, which may be helpful. Also, there is a forum under the Career section called "First Year After Licensure" where new nurses often post questions similar to yours, so you may find some useful information there. You may also find it helpful to use the search bar to look for topics such as "prioritization and organization of care" etc; these topics are frequently discussed, and you will be able to view a variety of contributions. I hope this is helpful. Best wishes to you.

Charge200J, BSN · Apr 11, 2018

You are doing great. Give yourself a pat on the back -- this stuff is tough. Try to "eyeball" your sicker patients at the start of your shift and trust your gut feeling on them. Use your brain sheet to stay organized and try to delegate some tasks to a tech or to your charge RN. I usually end up telling all my orientees as they get off orientation: you run your shift or the shift will run you. So it's totally ok to stop the chaos for a second, sit down and plan your next 3 moves. It will bring some order and control to a crazy shift.

Oh and for the "eating young nurses" issue: Take a deep breath when someone says something ridiculous to you. Make good eye contact, stand up a little straighter and thank them for their feedback/concern/etc. Then pick yourself up, brush yourself off, and move on. You are above the cliquey stuff and you will be welcoming and compassionate to the next group of new hires. I know these growing pains hurt, but in a year you will look back and see how strong you have become. Hang in there!