This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum.

This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum. Please see the corresponding case study that may be used with it.

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

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) Definition There are many ways we can do things and many reasons for doing them in the order that is chosen. No two nurses actually think exactly alike so if given the same assignment they may be different in how it is carried out. I know, you are thinking, “How am I supposed to figure out what the NCLEX wants me to do so I can answer the question correctly?” There are some basic principles that any nurse should know and we will walk you through some cases to ensure you know what to do in each scenario.

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 These are some ways you may organize your care for the shift. In addition to these you can use the nursing process to prioritize your care. Assess first! And Always evaluate at the end.

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 We all know this one, this stems from the American Heart Association Basic Life Support. We should have instilled in you over the last several semesters AIRWAY, AIRWAY, AIRWAY! This should be an easy one. You have a patient with pain in a lower leg and a person in the midst of an asthma attack. Airway first! So of course you will check on the asthma patient first. Assess for that airway concern early – stridor, etc. 3-5 min of oxygen without oxygen is our window. Breathing – once we have established that the airway is open then we move on to the breathing pattern. Is it effective? Is the pt apneic? How can we fix it? Do we need to reposition? Do we need narcan to reverse the narcotics on board? Think of anything that could be effecting that breathing pattern Circulation – assess for the circulation issue. Is there an arrythmia? is the limb cool to touch? If you have a client who needs help ambulating to the bathroom and a client who reports his heart is running away with him, we would see the cardiac issue first. Disability is a wide variety of things it could be. Our main focus is to slow down the development of disability. For example, A patient with a high blood pressure who is beginning to have vision changes. We need to get the BP down so we do not have permanent damage. We could have a stroke in progress. Bottom line assess first!

Trends vs. Isolated Findings
Vital signs Pain scale Level of consciousness Glasgow Coma Scale Recognizing the gradual change or deteriorization is key. One low blood pressure that has resolved is not as important as a client whose blood pressure has continually risen over the last 12 hours without coming down. Someone’s pain that is not being resolved with current treatments should be seen before someone whose pain pill is effective each time it is given. A trend usually signifies something deeper or more serious is going on. Further assessment needs to be performed, the healthcare provider probably needs to be informed if they have not already. Further testing/diagnostics need to be ordered to see why the trend is there, why the deteriorization is happening.

Actual Problem vs. Potential Problem
Generally we treat an actual problem before a potential one. Yes there are always exceptions to every rule, however, in general – the problem that is already here should be taken care of before a problem that is not here and potentially may never get here. For example, 2 clients come in with rule out GI bleed. Both have a low hemoglobin. One, however, is also vomiting blood due to the active GI bleed. We are going to care for the one that has the vomiting blood before we care for the one that is bleeding somewhere, but not serious enough to need an NG tube and large bore IVs as the first client needs.

“Life over Limb” System vs. Local
System over local falls under that old adage life over limb. We need to fix the systemic issue over the localized issue. In emergency situations where the client has a broken arm and is not breathing. We fix the breathing first. There is no need to fix the broken arm if the patient dies due to lack of oxygenation. We treat shock over a laceration. Those type of situations.

Acute Problem vs. Chronic Problem
New injuries are always less predictable than an existing disease process. Existing disease processes are usually known by the pt and the pt has developed some level of adaptation. A new diagnosis such as confusion or chest pain needs to be cared for immediately. We need to assess and get to the route of the new diagnosis and ensure something serious is not emerging. Something chronic like diabetes, the pt often knows how to handle their hypo or hyperglycemia. A person with blood sugars out of control that has never had an issue with blood sugars before needs to be seen first to assess the etiology of the change. Bottom line see new and unpredictable before something you have been seeing and need to continue to work on.

Maslow’s Hierarchy Physiological – food, sleep, oxygen, sex, excretion
Safety – shelter, removal from danger Social – some call this love and belonging – love, affection, being part of a group Esteem- self esteem, being well liked Self actualization – achieving one’s individual potential

Time Management Immediately Within a specific time frame
By the end of the shift Least amount of time to complete Immediately- whats needs to be done immediately. Is there someone calling for antiemetic or analgesic? Is the OR waiting for the pt to get pre op order? Is a unit waiting to give you report on a pt being transferred to you? What needs to be done before anything else can be done for that patient? Do we need a consent before we send him to the cath lab? Within a specific time frame – What needs to be done by 11:30? What needs to be done before bkfst? When does the blood need to be infused by? When should the chemo be finished so the next bottle is on time? By the end of the shift- what is a priority but not right now? The teaching just has to be done before you leave your shift. The I&O needs to be done by the end of shift. Least amount of time- sometimes it is as simple as what can I get done quickly? I can give this pain med in 2 minutes before I go in to perform a dressing change on a bedridden patient that will take me 30 minutes or more. Still remember your other ways of looking at the same material. ABCD will take precedence over time management. But if all of your patients are stable then sometimes time management is the best way to go.

Infection Control Issues
See the most infectious patient last whenever possible. No matter how good we are with our application of PPE and hand washing the possibility of us passing an infectious agent to our next patient is very real. Some of our patients are very immuno compromised and will pick up anything that is close. For instance, when possible let us see the client with tuberculosis last. Save the patient with VRE until last. Never leave a room with a patient with chicken pox and go directly to a patient’s room that has a low white blood cell count due to a bone marrow transplant. This last one is extreme. These patients should not even be on the same floor, but you see the concept?

Conclusion… Read the entire question and highlight key words to decide which method to use to prioritize your care This conclusion is super important so I feel I need to read it to you just for the emphasis. Know what they are asking before you automatically say “AIRWAY!” Now let us use some questions to illustrate what we have just spoken about.

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)

A nurse receives the following change of shift report:
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 Look at instability, what is new, what has changed. The other things are expected for a client with this report.

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 ) A client who has an every 4 hour PRN analgesic prescription and who last received pain med at ) 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 ) A client who has an every 4 hour PRN analgesic prescription and who last received pain med at ) 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 See the most acute first, the least stable.

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 Time Management Principles- There is no need to collect the supplies until you are sure that the patient will accept the blood, you have educated the patient and obtained an informed consent for the blood. If you mentally envision the procedure then you should be able to get all the supplies needed and not have to leave in the middle of procedure to get something you have forgotten to pick up. This nurse clustered activities that made sense as well.

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 The patient is likely going into anaphylactic shock and epinephrine will prevent a cardiac collapse as well as an airway shut down.

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)

D) A 8 year old with Kawasaki disease who has a temp of 102.2
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 This child has the most acute problem. The crackles likely indicate that the child has severe left ventricular failure as a complication of endocarditis and will become hypoxic soon. The other children should be assessed as soon as possible but this child has life threatening issues.

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)

D) A 63 year old with MS who has an oral temp of 101.8F and flank pain
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 F and flank pain This patient likely has pyelonephritis which could become sepsis. The systemic effects are a concern. The other clients need to be seen as soon as possible but this patient is highest priority.

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 Okay, be careful with this one. Read it carefully – it is a negative question first of all. They are asking you which intervention is incorrect. They are saying that the UAP has been the one to perform all of these tasks. So in essence they are giving you clues by asking, can a UAP perform all of these tasks? The UAP can help with eating, help with bathing and can even remind a patient about what the nurse said, but the brace should not be placed by a UAP and the brace for a CTS patient should be in a neutral position not hyperextended.

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)

A) Diarrhea related to irritated bowel
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 Looking at Maslow the fluid loss of diarrhea should take precedence. All of these things are an issue but if we fix the diarrhea and the patient feels slightly better the others may fix themselves.

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.

This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum.

Similar presentations

Presentation on theme: "This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum.

Similar presentations

Presentation on theme: "This presentation is intended to satisfy the exemplar Prioritization under the concept of Managing Care in NUR 212 for the NC CIP Concept Based curriculum."— Presentation transcript:

Similar presentations

About project

Feedback