Prioritization

Critical Thinking
- the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used
to ensure safe nursing practice and quality care
- Steps
o Interpretation- identify the problem
o Analyze the situation
o Evaluate
o Make Inferences
o Possible Actions

Critical Thinking – Priority Setting Frameworks

1. Maslow’s Hierarchy of Needs
2. Nursing Process: Part of NCSBN nursing process. Gives you as a nurse a tool or system to help you obtain all necessary data and
information before being able to make a decision regarding what nursing action is appropriate to take regardless of setting or patient.
3. ABC’s: Airway, breathing, circulation are critical for survival, an altercation in one of these areas could indicate a threat. By
the way, what is the normal range of oxygen saturation? It is 95% or higher.
1. If you as a nurse walk in a patient’s room, the patient’s bed is flat, the patient was sleeping but she seems to be
having a hard time breathing – would you take her vital sign first? Or something else first?
4. Safety and Risk Reduction
1.

2.
5. Least restrictive/Least Invasive
1. Restraints – avoid applying if possible; exhaust all other options first

2.
6. Survival Potential
1. V

2.
7. Acute/Urgent/Unstable vs Chronic/Nonurgent/Stable
 1. Acute needs are usually given priority as they may pose more of a threat to patient
1. Pneumonia COPD

2.

Maslow Nursing Process Airway Breathing, Circulation

Safety and Risk Reduction Least Restrictive/ Least Invasive Survival Potential

Acute/ Urgent/ Unstable vs Chronic/ Nonurgent/

Stable
Critical Thinking leads to Critical Judgement

Reflection-in-Action vs Reflection-on-Action
- IN – active – while you are in the situation/ action
- ON – takes places after event has occurred
- Reflection: intentionally thinking back to discover purpose (how/why I chose action)

Putting it all together…

- First level: ABC
o Airway. (ie: npo, gag reflex, breathing, water after surgery, dysphagia after stroke)
o Breathing (ie: breath sounds, o2 admin, o2 status pulse ox, raise hob, incentive spirometry)
o Circulation (ie: HR, BP, CPR, fluid status (fluid deficit or overload), diarrhea, pulses, IV fluids, TPN, central lines,
bleeding hemorrhage)
- Second level MAAUAR – 2 additional levels after the ABC’s
o Immediate or urgent concerns (ie physical restraints)
o Safety (ie: physical (walking after narcotics, bedrails, restraints..) and Psych- mental status changes)
o Pain (rate on scale; moaning, etc)
o M-A-A-U-A-R which stands for:
 M ental status changes and alterations
 A cute pain
 A cute urinary elimination concerns
 U naddressed and untreated problems that require immediate priority attention
 A bnormal laboratory and other diagnostic data that are outside of normal limits and
 R isks including those relating to a healthcare problem like safety, skin breakdown, infection and other
medical conditions
- Third level priorities include all concerns and problems that are NOT covered under the 2 level priority needs and the ABCs.
o Education (what is happening and why)
o Feelings. (emotions, concerns, anxiety, psych diagnosis or not)

When to call the provider?

- Ask yourself a very simple question:
- Does the patient have an immediate/significant need that I need to address before leaving the room? (airway issue,
hemorrhaging, fallen)

Before calling the provider, save yourself some steps by gathering some information first:
- If a vital sign is abnormal:
o LOOK at the patient- symptomatic or not?
 o Double check it: do it manually
o Check trending vitals
- If the patient needs a medication:
o Check the chart, is it ordered?
o What was the last set of vitals? Do you need to recheck?
o What are the patient’s allergies?
o Have they ever had the medication before?
 If it is a home med, is the medication in the chart correct? (5 rights)
 If it is a pain medication, when was the last dose? What is their pain score?
- If there is a change in patient condition:
o Does the change involve the ABCs?-If so, assess for life threatening issues and call for help. Have someone else get
the doctor, do not leave the patient.
 If patient is stable:
 Get a full set of vitals
 Check to make sure there aren’t orders in for you to address the situation. Ie: Tylenol for fever
 Check if there are nursing protocols you can initiate without a doctor.
 Get lab results (most current and trending)- how are they? Relationships?
 Assess the patient for symptoms. ie: Patient has a low HR-Are they dizzy-do they feel SOB?
o *Stay calm! Keep a clear so you can Critically think!

Example:
*You go to a party where everyone is having fun, drinking alcohol (big bucket of Jungle juice and beer) and eating snacks. You notice
that your new roommate is across the room on a chair by herself and looks to be asleep. You’re pretty sure she has been drinking
but also know that she is allergic to nuts. You walk over to see if she is ok and find that she is not waking up
- Assess breathing
- Get epi-pen ready (in case of possible allergic reaction to nuts)
- Sternal rub if she is unresponsive

Additional Principles of Prioritization

- Available resources and staff
- Qualifications of staff
- What things can be delegated to others
- How much time is involved in some skills (things that take more time may be done later)

A 28 year old patient with a torn Anterior Collateral Ligament (ACL) repair yesterday has an order for 5 mg of morphine every 3
hours as needed. The client has declined the medicine since the surgery but you notice he has clenched teeth, is diaphoretic and
hasn’t slept much. Which action by the nurse is most important?
a. Administer the 5mg of morphine to the patient
b. Explain the process of addiction to the patient
c. Ask the client to rate their pain on a scale of 1-10
d. Determine why the client is declining the medication

Priority Patient Scenario

To help establish priorities with multiple patient assignments, the following is a scenario of patients you have been assigned to care
for on a cardiac telemetry floor. Based on application of priority setting principles, which of these three patients do you see first, and
why?

Prioritization of Patients – BB – How would you prioritize the patients?

Patient #1:
Mark Sullivan is a 78-year-old man who had coronary artery bypass graft x3 vessels. He transferred out of ICU earlier today
and is postoperative day (POD) #2. He has no history of dementia or ETOH use/abuse. He has been forgetful and does not
consistently remember why he is in the hospital. He requires frequent orientation. You can hear Mark yelling, “I got to get
out of here! I need to get back home right now. My wife needs me!”

Patient #2:
 Mary Johnstone is a 65-year-old woman who was admitted from the ED earlier today. She has a history of hyperlipidemia,
hypertension, myocardial infarction, and coronary artery bypass graft surgery x3 vessels six months ago. The past week she
has had mid-sternal chest pressure that radiates into the left arm with exertion but relieves when she rests. She came into
the ED when she experienced the same pressure while at rest this morning.
She put on her call light and states that she is still having chest pain. She is on a nitroglycerine intravenous (IV) gtt at 20
mcg/hour, as well as a heparin IV gtt at 1200 units/hour.

Patient #3:
Joe Sandberg is a 52-year-old male who has no prior cardiac history who was admitted yesterday to cardiac telemetry for
mid-sternal chest pressure that radiated to his neck the past two weeks with moderate levels of exertion. Coronary
angiogram identified a 90% proximal right coronary artery lesion. He had a PTCA and placement of a drug eluding (DES)
coronary artery stent to the RCA with a residual stenosis of 5%.
The angiogram revealed the following hemodynamics:
-  55% ejection fraction
-  Cardiac output: 5.9
- Cardiac index: 3.1
- Pulmonary artery pressures: 35/15

He has just arrived to your telemetry unit from the cath lab. He has no report of pain. His right arterial and venous sheaths
were removed in the cath lab. Groin site is soft, and distal pulses are 2+ and palpable.

Who Do You See First?

- Based on the recognition of relevant clinical data, which patient would you see first?
- What clinical data did you identify as relevant to support your clinical judgment?
- Who would you see second?
- What clinical data did you identify as relevant to support your clinical judgment?
- Who would you see last?

Based on the recognition of relevant clinical data, which patient would you see first?

Basics of Delegation
- RN (delegator) remains accountable for the care of all clients by the team
- As a rule:
o RN’s- never delegate critical patients, Assessments, Care planning and client education. *Can to another RN only
o LPN’s- more stable patients, chronic patients
o UAP’s /NA’s- tasks- and be sure you discuss when to report back

Communication is KEY
- Always communicate with others on your team
- Give specific directions of the care and your expectations
- Check back in frequently
- Huddle as needed

Put it all together

- You are the leader of a team providing care for six clients. Your team includes yourself (an RN), an LPN/LVN, and a newly
hired UAP who is undergoing orientation to the unit. The clients are as follows:
o Mr. C, a 68-year-old with unstable angina who needs teaching for a cardiac catheterization scheduled this morning
o
Ms. J, a 45-year-old experiencing chest pain scheduled for a graded exercise test later today
o
Mr. R, a 75-year-old who had a left-hemisphere stroke 4 days ago
o
Ms. S, an 83-year-old with heart disease, a history of myocardial infarction, and mild dementia
o
Ms. B, a 93-year-old newly admitted from a long-term care facility, with decreased urine output, altered level of
consciousness, and an elevated temperature of 99.5° F (37.5° C)
o
Mr. L, a 59-year-old with mild shortness of breath and chronic emphysema
For which clients should you assign the LPN/LVN to perform nursing care tasks, under your supervision? (Select all that apply)

1. Mr. C
2. Ms. J
3. Mr. R
4. Ms. S
5. Ms. B
6. Mr. L

Which client should you assess first?

1. Mr. C
2. Ms. J
3. Ms. B

The health care provider's orders for Ms. J, who is currently experiencing chest pain, are as follows. List the orders in the sequence in
which they should be completed. (Answers may be used more than once.)
1. Monitor blood pressure and heart rate.
2. Place on a telemetry monitor.
3. Obtain a 12-lead electrocardiogram (ECG) when the client experiences chest pain.
4. Administer nitroglycerin (Nitrostat) 0.6 mg sublingually every 5 minutes as needed for chest pain.
5. Administer morphine 2 mg IV push as needed for chest pain.