A nursing student and a new graduate nurse have one primary thing in common- they are both utterly perplexed at prioritizing their lengthy to-do list. The nursing process dictates that the nurse’s first responsibility is to assess, then diagnose, and then plan how to manage their patients before implementing any life-saving interventions for which nursing school prepares us. Those first three steps are crucial to everyday success as a nurse, especially when the expectation for the average medical-surgical nurse is to manage as many as six or more patients. By evaluating the patient and their diagnoses systematically and logically, considering multiple perspectives, even a rookie nurse can identify which matters merit nursing priority attention.
The first step in the prioritization process is to gather all the relevant information. This need for data is why most nurses start their shift by obtaining a direct hand-off from the off-going nurse, followed by directly assessing their patients and their medical charts to prioritize interventions based on a comprehensive understanding of their patient’s condition(s) and needs. Only after evaluating this information can the nurse develop appropriate nursing diagnoses. According to NANDA International and last amended in 2013, a nursing diagnosis is “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. [It] provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability”.
Nursing diagnoses are based on available data (historical, assessment, vital signs, and laboratory data) gathered during the nurse’s assessment. They are within the nurse’s autonomy to manage without a physician or clinician order. The planning step involves prioritizing the existing diagnoses based on the nurse’s clinical judgment. While this clinical judgment may be slower or slightly less accurate in a student or novice nurse, it is not impossible.
Most textbooks will assist in outlining methods to help novice nurses identify which patients require priority assessment. In trauma settings, patients are categorized into triage levels based on their presenting illness or injury severity. Level 1 patients have emergent or life-threatening injuries or needs such as respiratory distress, chest pain, or stroke. Level 2 patients have urgent but not life-threatening conditions. These need to be assessed and managed quickly to avoid significant morbidity but are unlikely to lead to mortality (e.g., renal colic, severe abdominal pain, and complex or open fractures). The final classification of patients is nonurgent and includes those presenting with injuries or illnesses that do not need to be managed immediately (e.g., musculoskeletal strains or sprains, simple fractures, or symptoms of an upper respiratory virus). This triage should be based on the primary survey, which includes an initial assessment to identify any massive external bleeding. Studies indicate that uncontrolled bleeding should be addressed first with external pressure (e.g., application of a tourniquet) to limit blood loss.
Beyond this, the acronym A-B-C-D-E is utilized. The trauma patient’s airway and cervical spine should be stabilized first, following by breathing to establish adequate ventilation. Circulation should be assessed next, including cardiac function, bleeding, and perfusion. D, or disability, describes the process of assessing a trauma patient’s level of consciousness. This can be brief and does not need to be an in-depth neurological exam initially. Finally, assessing the patient via exposure includes removing their clothing to complete a quick head-to-toe assessment for any additional injuries while avoiding hypothermia.
Through their BLS and ACLS certification program, the American Heart Association trains EMS and first responders on prioritizing life-saving interventions in the case of patients with collapse due to cardiorespiratory arrest. Historically, these priorities were recalled easily using the A-B-C acronym, which stood for airway, breathing, and circulation. Recently, this acronym was revised to C-A-B, as studies indicate that adults who collapse are more likely to be suffering from circulatory failure than respiratory failure. Survival rates improve when compressions and AED evaluation are done sooner, before rescue breathing. For that reason, if the arrest is witnessed, connecting the AED should be prioritized over rescue breathing.
While these previously described methods should be considered and utilized if appropriate, in most circumstances, the nurse is attempting to prioritize a group of patients on a hospital ward, not in a trauma or emergency scenario. Strategies to prioritize within a more traditional nursing environment include the general use of nursing diagnoses combined with Maslow’s Hierarchy of Needs. Abraham Maslow’s hierarchy of needs describes human needs in order of their importance graphically using a triangle (see Figure 1). His theory purports that for humans to achieve any level of that triangle, they must first fulfill the lower/preceding levels. Any nursing diagnoses that directly relate to survival or a threat to the patient’s mortality should be prioritized first. This may be related to the patient’s access to air, water, or food, defined as the necessities of survival. Maslow described these as the patient’s physiological needs, including rest and warmth, and comprise the most basic (bottom) level of his triangle. Examples of nursing diagnoses that might fall under this first category include Ineffective airway clearance and Deficient fluid volume. The second level is patient safety and security. Examples of safety diagnoses that should be highly prioritized include Risk for injury and Risk for suffocation. These first two levels combine to create what Maslow described as basic needs.
The next grouping of diagnoses includes those related to the social or psychosocial needs of the patient, which are typically prioritized last. The third and fourth levels of the triangle include psychological needs: belongingness or love (e.g., unconditional love from parents, acceptance of friends, intimate relationships) and esteem needs (e.g., feelings of accomplishments, pride). Examples of social or psychosocial nursing diagnoses that the nurse would encounter include Ineffective role performance, Anxiety, and Social isolation. The pinnacle of Maslow’s triangle, self-fulfillment or self-actualization, includes achieving one’s full human potential. Following the use of this theory to its logical conclusion, the nurse should prioritize a patient’s need to breathe or eat over a patient’s potential risk for falls.
Maslow’s Hierarchy of Needs
The availability of resources (e.g., staffing, supplies, time) should also be considered when prioritizing nursing care. The patient’s preference may also be considered in certain circumstances. For example, consider the nursing diagnosis Self-care deficit: Dressing may not be an appropriate priority for that patient on that specific day if they prefer to spend the day in their pajamas after getting washed up. Similarly, a nursing diagnosis of Altered health maintenancemay not be the optimal choice in a patient who has expressed a lack of readiness to receive patient education regarding smoking cessation at this time.
Even with the best prioritization skills, a nurse cannot physically be in two places and perform two crucial tasks simultaneously. In most cases, delegation is the key to successfully managing multiple patients. Teamwork is essential. The nurse should collaborate with their coworkers and utilize their resources, including other nurses, unlicensed assistive personnel, and allied health professionals such as respiratory, physical, occupational, and speech therapists. By delegating appropriate activities and knowing when to ask for help, the nurse learns to function within the multidisciplinary team.