Prioritization of Nursing Care

2. Prioritization of Nursing Care Dr. Sheryl Cornelius, EdD, MSN, RN

3. 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

4. What is prioritization? Definition Prioritization is the organization of activities according to the order in which they should be done. ( Marquis, B. L. & Huston, C. J., 2009)

5. 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

6. Emergency First: A B C D A: AIRWAY • Assess for patent airway • Establish airway, if indicated • 3-5 minute window for oxygenation B: BREATHING • Assess breathing and its effectiveness • Intervene as appropriate C: CIRCULATION • Identify circulation concern • Act as appropriate to reverse circulatory problem. D: DISABILITY • Assess for disability • Act to slow down development of disability

7. Trends vs. Isolated Findings • Vital signs • Pain scale • Level of consciousness • Glasgow Coma Scale

8. Actual Problem vs. Potential Problem

9. System vs. Local “Life over Limb”

10. Acute Problem vs. Chronic Problem

11. Maslow’s Hierarchy

12. Time Management • Immediately • Within a specific time frame • By the end of the shift • Least amount of time to complete

13. Infection Control Issues • See the most infectious patient last whenever possible.

14. Conclusion… • Read the entire question and highlight key words to decide which method to use to prioritize your care

15. 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)

16. 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

17. 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)

18. 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

19. 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)

20. 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

21. 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)

22. 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

23. 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)

24. 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

25. 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)

26. 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

27. 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)

28. 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

29. 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)

30. 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

31. 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.

32. 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.

33. 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.

34. 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.