In nursing school, you learn how to create care plans which are, most likely, the bane of your existence (right up there with NCLEX questions and group projects). Chances are, you’ve probably wondered “how am I going to use this when I’m working as a nurse?” After all, it’s not like you’re going to sit down at the beginning of your shift and spend a few hours writing up a care plan for each patient (that’s the good news!). The bad news is that care plans still have a place in the real world (sorry!). However, you’ll be thrilled to know the process of addressing them in your charting is miles away from the grueling exercise you’re going through right now as a student (whew!)

Where all that care planning comes into play is the practice it gives you in identifying the real problems your patient is having and potential problems he could have. And it is from this foundation that you will begin to prioritize your patient care. How do we do this? It’s easy…we start by making a list.

The list of all the things

As you go through shift report, assess your patient and look through the chart, you are going to start zeroing in on all the abnormal findings. Start a list of all these things, but don’t worry about prioritizing them just yet…just get them down on paper. This list will become your “to-do” list, action list, list of all the stuff you’re gong to try to fix.

Next, you’ll make a list I like to call “all the things that could go wrong.” Knowing what you now know about your patient’s situation and problems, what potential issues could they face? You, the awesome nurse, are going to try like crazy to keep those things from happening.

So now you’ve got two lists. Your list of REAL problems and your list of POTENTIAL problems. Looks a lot like a care plan, doesn’t it (minus the convoluted language, of course). OK, now  you are ready to prioritize.

Prioritizing like a pro

Looking at your list of real and potential problems, you’re going to assign each item a rating.

  • A: Things that need to be addressed now (if you don’t, the patient will suffer serious harm)
  • B: Things that need to be addressed soon (you definitely can’t ignore these issues)
  • C: Things that need to be addressed today (not doing them would delay discharge or hinder routine care)
  • D: Things that can help progress the patient toward wellness (these tend to be the more proactive things like mobility, nutrition, and long-term therapies)

Now, depending on where you work, you may find that you have a lot of competing priorities. For example, in the ED or ICU, you might have several priorities at the same level…things that absolutely have to be addressed now or, at the very least, addressed soon. You will need to prioritize appropriately in order to provide the most benefit for your patient with the resources you have available.

For example, let’s say your patient has a hemoglobin of 6.8 and an O2 saturation of 86% on room air. Both of these things need to be addressed in a timely manner, so how do you prioritize?

Ask yourself, “what can I do RIGHT NOW to help this patient, and what is going to take a little longer?” In this case, you can place the patient on some oxygen right now and improve their oxygenation status pretty quickly. It takes just a moment to grab an oxygen mask or nasal cannula and the effect should be immediate (of course, there are always exceptions but we’re keeping things simple for this example). Getting blood transfused, though also very important, is going to take longer. Throw on the oxygen then page the doc to request some PRBCs. Though you had two items that needed your attention, you prioritized effectively and addressed both of them in a timely manner. Easy one, right?

How about this one? Your patient has about 15 meds to crush and give via an OGT (one at a time with the appropriate flushes in between), which can take a fair amount of time. She is also very fluid overloaded with 3+ edema for which the doc has ordered IV albumin followed by an IV diuretic. The albumin, being a large protein, should increase oncotic pressure and pull fluid into the vascular space. We then follow it with a diuretic in order to flush that extra fluid out through the kidneys. So, looking at all your OGT meds and this albumin/diuretic combo…how do you know which meds to give first?

Again, the question is…which of these meds is going to help the patient the most RIGHT NOW. You also want to take into account how long it will take to implement a particular therapy. If it were me, I’d get the albumin going first…give OGT meds while it is infusing, then follow the albumin with the diuretic. If you’ve got two antibiotics to give and only one available line, you have a couple of options. You can start another line and run them simultaneously…but what if that’s not a possibility? Maybe you have a renal patient with limited access and one IV is all you’ve got. If one of your antibiotics is to run over 30 minutes and the other is to run over 60 minutes…get the shorter one up first…this enables you to ultimately get antibiotiocs infusing in a more timely manner overall. Make sense?

Some questions to ask yourself

As you think about prioritizing and time management, ask yourself questions like: 

  • Is this an acute problem or a chronic problem? (acute problems usually take precedence over chronic ones)
  • What can I fix the most quickly? (If you have a choice between two interventions and they can both equally benefit the patient, do the fastest/easiest one first)
  • What could happen to the patient if I fail to act on this right now? (think about the patient’s safety and any life threatening situations!)
  • What can I delegate in order to maximize results? (use your resources!)
  • What can I delay safely so that I can get something more important done now? (sometimes you have to delay routine things when the unexpected comes up)
  • What can I do as the nurse and what do I need to get an order for? (do what you can to help the patient while waiting for those MD orders to come through)
  • Which treatment, diagnostic, assessment will make the most impact for the patient’s condition and should take priority? (nurses coordinate the patient’s care, so even though the doc has ordered multiple therapies/treatments/meds…it’s often up to you to manage how and when all this gets done.)

Hopefully these tips can help you with prioritization and time management…or maybe you’ve got a great tip of your own to share. Let us know in the comments below!

For even more strategies on time management, critical thinking and prioritization, check out my nursing school prep course Crucial Concepts Bootcamp.

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