Prioritization Flashcards
Critical Thinking is the process of
actively & skillfully conceptualizing, applying, analyzing, synthesizing, &/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief & action
Clinical Reasoning (Judgment)
collect signs, process information, understand the patient’s medical situation or problem, plan & implement appropriate medical interventions, evaluate outcomes, & learn from this entire process
Prioritization is
deciding which needs or problems require immediate action and which ones could tolerate a delay in response until a later time because they are not urgent
In emergencies, what prioritization need to considered first?
ABCD and V/Ls
_________ before potential
acute
____________ before local
Systemic
- life over limb
Acute before
chronic
- Acute is the least predictable new s/s and cascades down
Trends or isolated findings
trends
- VS, Pain, LOC, Glasgow coma scale
- gradual change and deterioration
What is the 1st level of priority setting?
ABCD
Vitals
Labs
What is the 2nd level of priority setting?
LOC changes
untreated concerns
acute pain
acute elimination problems
imminent risks
What is the 3rd level of priority setting?
health problems rather than 2nd level
chronic
issues in health education
rest
coping
etc
What should always be done 1st in prioritization?
Assessments and baseline
- color
RR/HR
Better or worse
Airway in ABCD
Assess for patency
establish airway if indicated
- blue, cyanotic, mottling
Breathing in ABCD
assess breathing effectiveness
- intervene
- chest rise, move, and equal on both sides, rate, skin color, O2 Sat, pattern, reposition, Narcan, reverse narcotics
Circulation in ABCD
identify concerns
act to reverse cirulatory problems
- pulse, EKG, cap refill, cold, color, 6 Ps, chest pain, SOB
Disability in ABCD
Act to slow down development of disability
What window does the patient have for oxygenation without an airway?
3-5 minutes
Confusion or chest pain needs
immediately taken care of
Maslow’s Hierarchy of Needs
- prioritization
Physiological
Safety
Love/Belonging
Esteem
Self-actualization
Maslow’s Physiological Needs
breathing
food
water
sex
sleep
homeostasis (balance of pain, fear, and anxiety)
excretion
Maslow’s Safety Needs
security of body
employment
resources
morality
family
health
property
Maslow’s Love/Belonging Needs
friendship
family
sexual intimacy
Maslow’s Esteem Needs
self-esteem
confidence
achievement
respect of others
respect by others
Maslow’s Self-actualization Needs
morality
creativity
spontaneity
problem-solving
lack of prejudice
acceptance of facts
Priority Words
first
initially
essential
best
primary
most right
Time Mgmt
make a list
schedule blocks
prioritize
Goal setting, priority determination, daily planning, delegation, evaluation, analysis
Prioritization Based on Acuity
identify problems of each pt
review active problems and goals
Most urgent based on needs, changing or unstable status, and complexity
The nurse receives report on for assigned patients. Which patient should the nurse assess first?
Patient one hour post op laparoscopic cholecystectomy for gall stones. He reports right shoulder pain.
Patient four hours post op tracheostomy who has a small amount of pink drainage on the tracheostomy dressing.
Patient 48 hours post op abdominal hysterectomy who is ambulatory and reports aching in the right leg.
Patients three days post open gastric bypass he reports fever and foul smelling discharge at surgical site.
Patient 48 hours post op abdominal hysterectomy who is ambulatory and reports aching in the right leg.*
A- is expected referred pain is expected
B- pink drainage is expected
C- This outcome points to DVT which is not expected.
D- this indicates infection.
Between C and D which one has the worst potential outcome? DVT could dislodge and cause a PE C is correct
Clinical Judgement order
Recognize cues: What matters most?
Analyze cues : What could it mean?
Prioritize hypothesis: Where do I start?
Generate solutions: What can I do?
Take action: What will I do?
Evaluate outcomes: Did it help?
Recognize and Analyze Cues
What do you notice and what is relevant?
What is abnormal?
- LOC, positioning, eye mvmts, talking, attentive, color, hygiene, monitors and EKGs, VS, SCDs, foley, contamination, falls, restless(hypoxia)
Chest rising
Why abnormal? And meaning behind it?
What could be the meaning of that?
Interpret the meaning (high/low, patho)
What is the clinical significance of the cues?
What are the problems?
What is most important in the problems?
Are there any trends/patterns occurring and what is the meaning?
A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case?
- Assess the amount and color of urine; obtain a specimen for a urinalysis and culture.
- Administer the prescribed antipyretic and notify the primary health care provider of this change.
- Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity.
- Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour.
- Administer the prescribed antipyretic and notify the primary health care provider of this change.*
A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item?
- Black, tarry stools
- Frequent nausea
- Joining Alcoholics Anonymous
- Pain that increases after meals
- Black, tarry stools*
The nurse is reviewing a plan of care for a patient who experienced a traumatic amputation of a leg the previous day. Which intervention listed on the plan is of lowest priority?
- Teaching residual limb care
- Monitoring hemoglobin levels
- Maintaining the compression dressing
- Using therapeutic interviewing techniques
- Teaching residual limb care*
Clinical Judgement in Pt Teachings
Readiness to learn – able to or best time (family helping?)
What is most important to them to learn
Learning preferences (style = verbal, resources, visuals, doing)
Cognition/language (can they understand
Domains of learning
cognitive, affective, psychomotor (insulin)
Barriers to learning (devices)
Therapeutic communication
Simple to complex and summarize main points
Knowles Fundamental Principles of Client Readiness
- learn what matters to the patient
- immediate learning and how they learn the best
- assess any anxiety and the time availability to teach as well as the environment
- language
SMART
SMART
- specific measurable achievable relevant and time bound
A nurse is preparing for a teaching session with a patient. Which of the following action should the nurse take to provide the patient with unbiased care? (select all that apply)
Avoid assumptions about the patient.
Compare the patient to a former patient.
Ask coworkers, to share their past experiences with similar patients.
Control personal thoughts about the patient.
Collaborate with another nurse to develop teaching strategies.
Avoid assumptions about the patient. *
Control personal thoughts about the patient.*
Collaborate with another nurse to develop teaching strategies.*
A nurse is participating in a question-and-answer session with a patient. Which of the following domains of learning uses this type of patient education?
Cognitive
Affective
Psychomotor
Adaptation
Cognitive*
A nurse is providing teaching to a patient who speaks a different language than the nurse. Which of the following action should the nurse take?
As the patient’s family member to translate.
Request a medical interpreter to be present.
Ask another nurse on the unit to translate.
Provide the patient with only written materials.
Request a medical interpreter to be present.*
A nurse is admitting a patient for surgery. Which of the following questions should the nurse asked to determine the patient’s health literacy level in learning needs?
Who will be your support person while you were in the hospital?
Can you tell me what surgical procedure you are scheduled for?
How do you plan to care for yourself when you go home after surgery?
How comfortable are you with filling out medical forms by yourself?
How comfortable are you with filling out medical forms by yourself?*
A nurse is preparing to educate a patient about the proper procedure for a dressing change. Which of the following indicates an understanding of Knowles’s fundamental principles of patient readiness?
-The patient states, “I will do it myself.”
- The patient has been awake all night.
- The patient is engaged and alert.
- The patient used to help change their partner’s dressings.
- The patient is engaged and alert.
Clinical judgment in evaluation
Evaluate your interventions and reflect
Did it help?
Did you get to the expected outcome?
Is the patient better or worse?
Have you had a change in condition?
Is the treatment working?
Has the patient obtained their goals?
Have the problems resolved?
- Reassess the patient condition to determine achievement of expected outcomes.
- Evaluate efficacy of nursing actions determine if patient outcomes were met.
- Modify patient outcomes and or nursing actions based on patient response.
- Update and revise the plan of care.
A nurse is reviewing a client’s plan of care. “The client will ambulate 20 feet using a walker” is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome?
-Specific
-Timed
-Measurable
-Achievable
-Timed*
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient’s headache. What is the nurse’s next priority action for this patient?
- Eliminate acute pain from the nursing care plan.
- Direct the nursing assistant to ask if the patient’s headache is relieved.
- Reassess the patient’s pain level in 30 minutes
- Revise the plan of care.
- Reassess the patient’s pain level in 30 minutes*
A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of impaired physical mobility. Before discontinuing the patient’s plan of care, what does the nurse need to do?
- Determine whether the patient has transportation to get home.
- Evaluate whether patient goals and outcomes have been met.
- Establish whether the patient has a follow-up appointment scheduled.
- Ensure that the patient’s prescriptions have been filled.
- Evaluate whether patient goals and outcomes have been met.*
The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility?
- The patient is able to ambulate in the hallway with crutches.
- The patient’s level of mobility will improve.
- The nurse provides assistance while the patient is walking in the hallways.
- The patient will deny pain while walking in the hallway.
- The patient is able to ambulate in the hallway with crutches.*
The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
- Staff documentation of turning the patient every 2 hours
- Absence of skin breakdown
- Presence of redness only on the heels of the patient
- Patient’s eating 100% of all meals
- Absence of skin breakdown*
Alarm Fatigue
Excessive exposure to alarms causing desensitization
Results in delayed or No response to alarms (nonactionable)
#1 = safety hazard and sentinel events
Expected goal of preventing alarm fatigue
maximize alarm functionality, settings, response time, and policy adherence to increase patient safety
Alarm Improvement Initiatives
- change pulse oximetry probe daily or PRN
- change cardiac electrode pads daily to significantly reduce alarms (false)
- customize alarm parameters specific to the patient (and per policy)
- remove duplicate alarms
- assume all alarms require a nursing response
CEASE
C- communication
E- electrodes
A- appropriate
S- set-up
E- education
I-SBAR-R-D
Identification ( yourself and patient)
Situation (name/age/primary problem, admission or post-op)
Background (diagnosis, relevant med hx and data)
Assessment (VS, findings, labs, abnormal, pt response, stable/unstable/worsening)
Recommendation
Repeat-Read-back (confirm
Document (conversation and new orders)
