Prioritization by Organ
This is the tie breaker for prioritization questions
What is the vital organ that is involved
This patient has the highest priority:
A. Myocardial Infarction
B. Atrial Fibrillation
C. Angina Pectoris
D. Congestive Heart Failure
What is A?
B, C, D are stable/chronic
This is the most important part of a prioritization question:
Age
Gender
Diagnosis
Modifying Factor
What is the Modifying Factor?
(Ignore gender and age - unless Pediatric Patient)
Newly Diagnosed
What is UNstable
This is the acronym for tasks a nurse cannot delegate to an unlicensed assistive personnel
What is EAT?
Evaluate
Assess
Teach
This is the vital organ of highest priority
What is the brain?
(anything that directly affects the brain such as high fever, seizure, stroke, hypoglycemia, etc)
This is the first rule a nurse will use to prioritize which patient to see first
What is acute vs chronic or stable vs unstable?
This patient will be your highest priority:
A. 23 yr old male with CHF, a potassium of 6.6 and no ECG changes
B. Chronic Renal Failure with a creatinine of 20.7 and pink, frothy sputum
C. Acute hepatitis with jaundice, increased ammonia levels and cannot be aroused
What is C (Acute and affecting the highest priority organ: brain since he cannot be aroused)
Post-op >12 hours
What is stable (>12 hours)
Patient would be unstable if surgery was <12 hours ago
These are tasks that cannot be delegated to a UAP (select all that apply)
A. Encourage patient with COPD to eat his lunch
B. Obtain vital signs on a fresh post-op patient until the nurse can see them
C. Assist a patient who had a hip replacement this morning to the chair for the first time
D. Measure and record urine output
What are B and C?
UAPs cannot do the FIRST anything on patients such as first set of vitals, first time with ADLs on post-op, etc.
This is the second vital organ for prioritization questions.
What are the lungs?
This is the patient you will see first:
A. COPD
B. CHF
C. Appendicitis
D. 2 hour post-op cholecystitis
E. 3 day post-op CABBGE
What is D?
2 hour post-op (priority if <12 hours)
This patent is most unstable
A. Angina Pectoris with unstable BP
B. Myocardial Infarction with stable VS
C. Post-op appendectomy (1 day)
A. UNSTABLE BP makes this one unstable
Newly Diagnosed (stable or unstable?)
What is UNstable
(new)
This is the patient an LPN can be assigned to:
A. A client with a history of chronic alcoholism experiencing delirium tremens
B. A client with bipolar disorder and a Lithium level of 2.0 mEq/L
C. A client with dementia that is confused and disoriented
What is C?
A and B are unstable and require a care of an RN
This is the Vital Organ that is associated with the 3rd letter in the ABC algorithm and is also the 3rd organ in prioritization
What is Heart?
All of these have what in common?
Hemorrhage
Fever >105 (seizures)
Hypoglycemia
Pulseless
Breathlessness
What are patients who are highest priority?
This patient will have the highest priority:
A. 16 yo female with meningitis with a temp of 102.9 since admission 3 days ago
B. 67 yo male with IBS who spiked a temp of 101.0 this afternoon
C. 22 yo female with asthma who is requesting a breathing treatment for increased wheezing
What is B?
IBS does not regularly cause fever and it is new/unexpected
Meningitis with fever is expected
Wheezing with asthma is expected
Stable or Unstable
Mild chest pain while having an abdominal x-ray
What is UNstable?
This is an unexpected finding
This is the patient you should assign to a float from the Neuro ICU:
A. A 20-hour postpartum client who will be discharged the following morning
B. A 10-hour postpartum client who has soaked 4 perineal pads in one hour
C. A 5-hour postpartum client whose fundus is still not at the midline
D. A 2 day postpartum client who had eclampsia during delivery
What is D? Eclampsia likely caused seizures which is a medical condition that the float will likely have experience with.
A, B, C are all acute and unstable
This is the priority patient the nurse will see first:
A. Patient with a potassium of 6.6
B. Patient with a PE and pink, frothy sputum
C. Patient who will not arouse
What is C?
Brain: 1st
Lungs: 2nd
Heart: 3rd
A patient who is deemed "unstable" will have these characteristics
What are unexpected signs and symptoms and complications
This is the patient you will see first:
A. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain
B. Client who has just arrived from the emergency department with facial burns sustained in a house fire
C. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
What is B? He JUST arrived so it's a new onset injury.
Stable or unstable?
Patient with kidney stones experiencing severe abdominal pain
Stable: pain is expected with kidney stones
These are the key words to alert you to tasks that should NOT be delegated to a UAP
What are:
show
explain
monitor
teach
check
assess
demonstrate