prioritization and delegation, priority setting Flashcards
first level
priority setting
life threatning priorities
- interventions that address ABC’s
second level
priority setting
nonemergent problems
- getting meds in, pt being discharged but no teaching yet, personal care such as peri care to pt who is incontinent
third level
priority etting
overall wellbeing
- personal care, how pt copes, nice to do things
factors for identifying priority pt
- age: the older the pt the higher the risk for complications
- admission date: the more recen the admission the moremlikely they are more acute and can change status quicker
- surgery date: the more recent the surgery the higher chance for complications
- body systems involved: morr systems involved the higher for adverse events
- gut: what is your gut feeling
5 rights of delegation
right… person, task, circumstances, direction and communication, supervision and evaluation
tasks you are allowed to delegate
ones that do not require the expertise of an RN
4 C’s of direction
- concise: is there too much info
- correct: policy, procedure, scope of practice, law
- complete: have i given all necessary info for person to complete task
- clear
prioritization pathway
safety –> nurisng process (assessment) –> pt needs
A
alpha prioritization chart
airway
- obstruction (choking)
- stridor
- excessive secretions
- swelling in upper airway
B
alpha prioritization chart
breathing
- resp rate too slow or fast
- distressed breathing
- low O2 sats
- need for pulmonary toileting
C
alpha prioritization chart
circulation
- low or high BP
- low or high HR
- low urine output
- RBC, HgB, Hct, Pit, D-dimer, PT, aPTT
- weak or absent pulse
- diminished cap refill
D
alpha prioritization chart
disability
- neuro status
- altered level of consciousness
- GCS
- pupil size and reaction
- pain
- low or high blood sugar
E
alpha prioritization
exposure/environment
- exposure to toxin
- infection
- altered skin integrity
- shock
- increased or decreased temp
- WBC, lactate, CRP
F
alpha prioritization
fluid and electrolytes
- loss through vomiting, diarrhea, diaphoresis, tachypnea
- nausea w/ or w/out vomiting
- IV lines
- fluid, rate, volume
- I/O
- urine output
- drains and tubes
- K, Na, Cl, Gluc, BUN, Cr, Mg, Ca, Phos, ALKphos, ALP, ALT
G
alpha prioritization
Goals for care
- diet orders
- activity/rest orders
- personal care, grooming
- pt education, discharge planning
- family coping/support
H
alpha prioritization
history
- chronic diseases
- previous surgeries
- home medications
important questions for determining priority
- does the client data match what the patient is presenting with
- what is worst case scenario
- is it a potential or actual problem
