Prioritization by Organ
What is the tie-breaker for prioritization Questions
The vital organ involved.
Which patient has the highest priority?
1. Myocardial Infarction 2. Atrial fibrillation
3. Angina Pectoris 4. Congestive Heart Failure
MI
(most acute)
What is most important in a prioritization Question:
-Age -Gender -Diagnosis -Modifying Factor
What is the Modifying Factor
Ignore age and gender
Newly Diagnosed
What is an unstable patient
Eat
Assess
Teach
DO NOT delegate what you can EAT!
What is the vital organ of highest priority
Brain
First Rule for Nurse to prioritize patient assignment
Most stable vs unstable
Acute vs Chronic
Highest priority:
A. 23 yr old male with CHF with 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 and increased ammonia level, who you cannot arouse.
C. Acute hepatitis with jaundice and increased ammonia level, who you cannot arouse.
(cannot rouse modifying factor)
Post-op 14 hours and no sign of trouble
Stable because greater than 12 hours
Less than 12 hours would be considered unstable
-Maintain and document IV flow
-Reinforce teaching
What are things you may delegate to an LPN
What is the second vital organ for answering prioritization questions
Lung
Which patient should the nurse see first
1. CHF 2. Appendicitis
3. Two-hour post-op cholecystitis
4. Three-day post-op CABBAGE
Two-hour post-op cholecystitis
(fresh post-op within 12 hours is most acute)
Angina pectoris with unstable BP
Myocardial Infarction with stable Vital signs
Angina Pectoris with unstable BP
(modifying factor most important)
SOB in patient who has had COPD for 20 years
Stable patient
UAP assists the new post-op patient up to the BSC
What are things that can not be delegated to the UAP
UAPs can be delegated ADLs but they should never do the first) This is a new post-op patient
What is the vital organ associated with the third letter in Airway Breathing Circulation of Maslow's prioritization and is also the third organ in prioritization questions
Heart
Hemorrhage
Fever >105 (seizures)
Hypoglycemia (<70)
Pulseless
Breathlessness
Always high priority
What is the highest priority patient
1. 16 yr-old female with meningitis who has had a temp of 103.8 since admission 3 days ago
2. 67 yr-old male with IBS who spiked a temp of 100.3 this afternoon
67 yr-old male with IBS who spiked a temp of 100.3 this afternoon
BECAUSE...A patient with Meningitis is expected to have a fever. A patient with IBS who recently developed a fever is an unexpected and new symptom.
Stable or Unstable: Mild chest pain while having a chest x-ray
UNSTABLE because unexpected sign
Which task can the Nurse delegate to the UAP?
A. Silence the IV pump B. Insert Foley Catheter
C. Administer enema D. Check patient's swallowing reflex
What is administer an enema?
What is the priority patient the nurse should see First
Potassium 6.6
Pink, frothy sputum = PE
Cannot arouse
heart (3rd organ)
Lung (2nd organ)
brain (1st organ)***
What unstable patients experience
Unexpected signs and symptoms
Complications
What is the variable you ignore in prioritization
Diagnosis
Kidney stones with severe colicky pain
Stable because expected sign
Name a med that a UAP may administer
What is Topical, over-the-counter, barrier creams