Transcript Prioritization of Nursing Care - NC-NET

PRIORITIZATION OF NURSING CARE
Dr. Sheryl Cornelius, EdD, MSN, RN
Objectives:



Define prioritization and the concepts surrounding
prioritization of patient care
Compare and contrast ways to base the
prioritization of patient care
Utilize principles of prioritization to determine
which patient needs to be seen first
Definition
What is prioritization?
Prioritization is the
organization of activities
according to the order in
which they should be
done.
( Marquis, B. L. & Huston, C. J., 2009)
Ways to base the prioritization


Emergency first: ABCD
Respond to trends vs.
isolated findings

Actual before potential

Systemic before local

Acute before chronic

Maslow’s Hierarchy

Time Management

Infection control issues
Emergency First: A B C D
A: AIRWAY
 Assess for patent airway
 Establish airway, if
indicated
 3-5 minute window for
oxygenation
C: CIRCULATION
 Identify circulation
concern
 Act as appropriate to
reverse circulatory
problem.
B: BREATHING
 Assess breathing and its
effectiveness
 Intervene as appropriate
D: DISABILITY
 Assess for disability
 Act to slow down
development of
disability
Trends vs. Isolated Findings

Vital signs

Pain scale

Level of consciousness

Glasgow Coma Scale
Actual Problem vs. Potential Problem
System vs. Local
“Life
over
Limb”
Acute Problem vs. Chronic Problem
Maslow’s Hierarchy
Time Management



Immediately
Within a specific
time frame
By the end of the
shift

Least amount of time
to complete
Infection Control Issues

See the most
infectious patient
last whenever
possible.
Conclusion…
Read the entire question
and highlight key words
to decide which method
to use to prioritize your
care

Question 1
A nurse receives the following change of shift report:
35 year old admitted yesterday after surgery for a ruptured appendix
Diagnosis: Peritonitis secondary to a ruptured appendix
Vital signs: T 101 F, P 108/min, R 26/min, BP 148/78 mm Hg, O2 1 L/min per
NC, Pulse oximetry readings have decreased from 98% to 89% over the
last 4 hr, NPO except for ice chips, Jackson Pratt drain: brown purulent fluid
moderate amount, D51/2NS at 100mL/hr IV, Morphine PCA,
AM Lab results: Hgb 2.0 g/dL(preop 12.8g/dL); Hct 37% (preop 39%),
Platelets 165,000/mm3 (preop 150,000/mm3),
WBC 23,500/mm3 (preop 18,700/mm3)
Based on the information provided in the change of shift report, the nurse
should assign initial priority to which reported client finding?
A) Jackson Pratt drainage
B) Heart rate
C) Temperature
D) Oxygen saturation level
LaCharity, Kumagai,& Bartz (2011)
Answer 1
A nurse receives the following change of shift report:
35 year old admitted yesterday after surgery for a ruptured appendix
Diagnosis: Peritonitis secondary to a ruptured appendix
Vital signs: T 101 F, P 108/min, R 26/min, BP 148/78 mm Hg, O2 1 L/min per
NC, Pulse oximetry readings have decreased from 98% to 89% over the
last 4 hr, NPO except for ice chips, Jackson Pratt drain: brown purulent fluid
moderate amount, D51/2NS at 100mL/hr IV, Morphine PCA,
AM Lab results: Hgb 2.0 g/dL(preop 12.8g/dL); Hct 37% (preop 39%),
Platelets 165,000/mm3 (preop 150,000/mm3),
WBC 23,500/mm3 (preop 18,700/mm3)
Based on the information provided in the change of shift report, the nurse
should assign initial priority to which reported client finding?
A) Jackson Pratt drainage
B) Heart rate
C) Temperature
D) Oxygen saturation level
Question 2
A nurse receives a change of shift report at 0700 for an assigned
caseload of clients. Choose the order in which the clients should be
seen.
1) A client who has been receiving a blood transfusion since 0400
2) A client who has an every 4 hour PRN analgesic prescription and
who last received pain med at 0430
3) A client who is going for colonoscopy at 1130 and whose informed
consent needs to be verified
4) A client who needs rapid onset insulin before the 0800 trays arrive
5) A client who is being discharged today and needs reinforcement of
teaching regarding dressing changes
A) 3,1,5,2,4
B) 4,2,3,5,1
C) 1,4,2,3,5
D) 2,3,1,4,5
LaCharity, Kumagai,& Bartz (2011)
Answer 2
A nurse receives a change of shift report at 0700 for an assigned
caseload of clients. Choose the order in which the clients should be
seen.
1) A client who has been receiving nitroglycerin for intermittent chest
pain since 0600
2) A client who has an every 4 hour PRN analgesic prescription and
who last received pain med at 0430
3) A client who is going for colonoscopy at 1130 and whose informed
consent needs to be verified
4) A client who needs rapid onset insulin before the 0800 trays arrive
5) A client who is being discharged today and needs reinforcement of
teaching regarding dressing changes
A) 3,1,5,2,4
B) 4,2,3,5,1
C) 1,4,2,3,5
D) 2,3,1,4,5
Question 3
A nurse is preparing to insert a second intravenous catheter (IV) in a
client who needs to receive packed red blood cells (PRBC) in
addition to his IV antibiotics. Using time management principles, in
which order should the nurse perform the following steps?
1) Mentally envision the procedure when collecting supplies for the
venipuncture.
2) Enter the room and perform hand hygeine.
3) Gain informed consent from the client for infusion of PRBC's.
4) Prepare the client and perform the venipuncture.
5) Follow protocol to obtain blood from the lab.
A) 2,1,3,4,5
B) 3,5,1,2,4
C) 1,2,4,5,3
D) 3,1,2,4,5
LaCharity, Kumagai,& Bartz (2011)
Answer 3
A nurse is preparing to insert a second intravenous catheter (IV) in a
client who needs to receive packed red blood cells (PRBC) in
addition to his IV antibiotics. Using time management principles, in
which order should the nurse perform the following steps?
1) Mentally envision the procedure when collecting supplies for the
venipuncture.
2) Enter the room and perform hand hygeine.
3) Gain informed consent from the client for infusion of PRBC's.
4) Prepare the client and perform the venipuncture.
5) Follow protocol to obtain blood from the lab.
A) 2,1,3,4,5
B) 3,5,1,2,4
C) 1,2,4,5,3
D) 3,1,2,4,5
Question 4
A few minutes after the nurse has given an
intradermal injection to a patient who is undergoing
skin testing for allergies, the patient complains
about feeling anxious, short of breath, and dizzy.
Which of the actions included in the emergency
protocol should the nurse take first?
A) Start O2 at 4L/min NC
B) Obtain IV access with a large bore catheter
C) Administer epinephrine (Adrenalin) 0.3 mL SQ
D) Give albuterol (Proventil) 2.5 mg via nebulizer
LaCharity, Kumagai,& Bartz (2011)
Answer 4
A few minutes after the nurse has given an
intradermal injection to a patient who is undergoing
skin testing for allergies, the patient complains
about feeling anxious, short of breath, and dizzy.
Which of the actions included in the emergency
protocol should the nurse take first?
A) Start O2 at 4L/min NC
B) Obtain IV access with a large bore catheter
C) Administer epinephrine (Adrenalin) 0.3 mL SQ
D) Give albuterol (Proventil) 2.5 mg via nebulizer
Question 5
After the nurse receives the change-of-shift report,
which client should be assessed first?
A) An 18 month old with coarctation of the aorta who
has decreased pedal pulses
B) A 3 year old with rheumatic fever who is
complaining of severe knee pain
C) A 5 year old with endocarditis who has crackles
audible throughout both lungs
D) A 8 year old with Kawasaki disease who has a
temp of 102.2
LaCharity, Kumagai,& Bartz (2011)
Answer 5
After the nurse receives the change-of-shift report, which
client should be assessed first?
A) An 18 month old with coarctation of the aorta who has
decreased pedal pulses
B) A 3 year old with rheumatic fever who is complaining
of severe knee pain
C) A 5 year old with endocarditis who has crackles
audible throughout both lungs
D) A 8 year old with Kawasaki disease who has a temp of
102.2
Question 6
After the nurse receives the change-of-shift report at 7:00
AM, which client should be assessed first?
A) A 23 year old with a migraine headache who is
complaining of severe nausea associated with retching
B) A 45 year old who is scheduled for a craniotomy in 30
minutes that needs pre op teaching
C) A 59 year old with Parkinson’s disease who will need a
swallowing assessment before breakfast
D) A 63 year old with MS who has an oral temp of
101.8F and flank pain
LaCharity, Kumagai,& Bartz (2011)
Answer 6
After the nurse receives the change-of-shift report at 7:00
AM, which client should be assessed first?
A) A 23 year old with a migraine headache who is
complaining of severe nausea associated with retching
B) A 45 year old who is scheduled for a craniotomy in 30
minutes that needs pre op teaching
C) A 59 year old with Parkinson’s disease who will need a
swallowing assessment before breakfast
D) A 63 year old with MS who has an oral temp of
101.8F and flank pain
Question 7
The nurse observes a UAP performing all of these
interventions for a patient with carpel tunnel
syndrome. Which action requires the nurse intervene
immediately?
A) Arranging the patients lunch tray and cutting his
meat.
B) Providing warm water and assisting the patient with
his bath
C) Replacing the patient’s splint in hyperextension
position
D) Reminding the patient not to lift heavy objects
LaCharity, Kumagai,& Bartz (2011)
Answer 7
The nurse observes a UAP performing all of these
interventions for a patient with carpel tunnel
syndrome. Which action requires the nurse intervene
immediately?
A) Arranging the patients lunch tray and cutting his
meat.
B) Providing warm water and assisting the patient with
his bath
C) Replacing the patient’s splint in hyperextension
position
D) Reminding the patient not to lift heavy objects
Question 8
A patient hospitalized with ulcerative colitis reports 10 to
20 small diarrhea stools per day, with abdominal pain
before defecation. The client appears depressed and
underweight and is uninterested in self-care or
suggested therapies. What is the priority nursing
diagnosis?
A) Diarrhea related to irritated bowel
B) Imbalanced nutrition: less than body requirements
related to nutrient loss
C) Acute pain related to increased GI motility
D) Ineffective therapeutic regimen related to treatment
plan
LaCharity, Kumagai,& Bartz (2011)
Answer 8
A patient hospitalized with ulcerative colitis reports 10 to
20 small diarrhea stools per day, with abdominal pain
before defecation. The client appears depressed and
underweight and is uninterested in self-care or
suggested therapies. What is the priority nursing
diagnosis?
A) Diarrhea related to irritated bowel
B) Imbalanced nutrition: less than body requirements
related to nutrient loss
C) Acute pain related to increased GI motility
D) Ineffective therapeutic regimen related to treatment
plan
Case Study
Concept: Managing Care
Exemplar: Prioritization
Course: NUR 212
Prioritization: You are the registered nurse (RN) and
you will have a group of six clients on a medical
surgical unit in an acute care setting. Based on the
following clients, answer the questions below.
The clients are as follows:
Room 101: A 19 year old female with asthmatic bronchitis and general anxiety disorder that has
been crying all night and is asking that no visitors are allowed. She is concerned about
missing her college classes due to the hospitalization and fears she may fail the semester. Each
time her anxiety increases her breathing worsens and she suffers an asthma attack with
bronchospasms.
Room 102: A 92 year old male with dementia and pneumonia. He has a bed alarm and has a
history of falls. He will not use the call bell when getting up to the bathroom.
Room 103: An obese 57 year old male admitted after a motor vehicle accident last night while
driving impaired. He has a chest tube for atelectasis. He has cardiac contusions and is on a
telemetry monitor in normal sinus rhythm. He has been sleeping soundly since the chest tube
was put in on admission 10 hours ago.
Room 104: A 54 year old female with uterine cancer. She is three days status post abdominal
hysterectomy with subsequent dehiscence of wound 12 hours post op. The wound is being
packed with normal saline soaked Nugauze three times a day. She is receiving chemotherapy
and is neutropenic on reverse isolation.
Room 105: A 67 year old male with Clostridium Difficile and Vancomycin Resistant Enterococcus
(VRE). He has been complaining of abdominal cramps and diarrhea all night. The stools have
subsided and he has just gone to sleep.
Room 106: A newly admitted 55 year old female with anemia and possible gastrointestinal (GI)
bleed that has not been assessed. She does not have an IV access. She will be receiving 2
units packed red blood cells (PRBC) ASAP.
Questions
1)Which patient should be seen first? Second? Provide rationale.
2) Which patient should be seen last? Provide rationale.
3) You have assessed everyone and are preparing to give AM meds and
treatments. Order the treatments and meds in the order that benefit the
patients. Provide rationale.
A) Xanax for Room 101who has increased respirations and is coughing
after receiving a call from her classmate.
B) A BID dressing change to abdomen in Room 104
C) Daily meds for Room 102 who has increased blood pressure that he has
not had prior.
D) Hang second unit of blood in Room 106
E) A call from Room 103 that he stepped on his chest tube on way to
bathroom and pulled it out and is having problems breathing.
References
LaCharity, L., Kumagai, C. & Bartz, B., (2011) .
Prioritization, Delegation, and Assignment. Port
Ludlow, Washington: Mosby, Elsevier.
Marquis, B. L. & Huston, C. J. (2009). Leadership roles
and management functions in nursing: Theory and
application. (6th ed.). Philadelphia : Lippincott,
Williams & Wilkins.
Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals
of Nursing: The Art & Science of Nursing Care. (7th
ed.) Philadelphia, Lippincott, Williams & Wilkins.