The purpose of this module is to discuss the nurse's role in safe and effective patient care through prioritization and delegation.
By the completion of this module, the nurse should be able to:
- Discuss the importance of prioritization in delivering patient care.
- Consider the application of ABC, Maslow, and the Nursing Process into the prioritization of patient care.
- Apply the concepts of ABC, Maslow, the Nursing Process, and time-sensitive indicators to prioritizing patient care.
Prioritization in Nursing Care
Nursing programs devote a significant amount of time and attention to teaching nurses how to prioritize their time to deliver safe and effective care. While in school, a vast majority of clinical training involves caring for one or two patients with oversight from faculty and nurse preceptors. However, once the graduate nurse is in the clinical setting, they are often faced with a much higher patient load and there are many things that demand the nurse’s attention. The ability to prioritize and manage time is vital for any successful nurse, whether a novice or expert. Yet, prioritizing and managing time is not necessarily information that can be memorized or easily taught in a textbook. There are many skills that converge to make safe decisions when delivering care to a group of patients (Jessee, 2019). This module will consider those skills and the most optimal ways nurses can provide care that is safe and effective through prioritization.
It is not unusual for a nurse to arrive on their unit and be tasked with assuming the care of up to six or seven patients with serious illnesses in a given shift. Nurses should remember they have a right to refuse any assignment they deem unsafe. However, once accepting the patient assignment, the nurse must determine how to proceed with the shift and meet the multifaceted demands of assessments, healthcare provider calls, administration of medications, patient advocacy, delegation of appropriate tasks to other members of the nursing team, facilitation of diagnostic testing, and family communication. Organizing all these demands can be quite challenging, and overlooking a step can lead to a medical error or a near-miss. While most nurses working consistently on the same unit will achieve competency of prioritization within their first year, there are situations where ongoing difficulty exists in managing patient care. For travel nurses with ongoing assignment changes, new graduate nurses, or nurses who are frequently reassigned to work on an outside unit, managing patients and performing appropriately and effective prioritization can be especially challenging. When removed from their "comfort zone," many nurses have difficulty acclimating to a different or unfamiliar environment. This difficulty may manifest as deficits in clinical reasoning and judgment which can interfere with prioritization and determination of the most pressing issues (Kavanagh & Szweda, 2017). Nursing school curriculum teaches nurses to utilize many resources to establish priorities including:
- Airway, breathing, and circulation (ABCs),
- Maslow's hierarchy of needs (basic needs first, see Figure 1 below),
- Nursing Process (see Figure 2 below),
- Time-sensitive indicators that are relevant in the acute care setting
- healthcare provider's orders,
- medication administration
- patient data interpretation,
- knowledge recall about patient conditions,
- triaging or ranking of patient risks (Jessee, 2019).
Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).
Maslow's Hierarchy of Needs
Abraham Maslow was a psychologist who created the hierarchy of needs triangle to demonstrate human needs and their order of importance. According to his theory, needs that are lower on the triangle should be met prior to those higher on the triangle. If basic needs are missing, the higher-level needs are not likely to be met. The bottom four levels are recognized as deficiency needs and the top level, self-actualization is known as "being" needs; this level is often not achieved by everyone. The nurse's focus during patient care is focused on the lower level needs when prioritizing care. Physiological and safety needs are basic requirements for positive patient outcomes (McLeod, 2020).
Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical career to direct patient care and determine priorities. The nursing process steps are:
- Assessment (noticing what is going on with the patient)
- Analysis (interpreting what is going on with the patient through reviewing lab work, diagnostic testing, patient history, complaints and observations)
- Planning and Implementation (responding to the needs of the patient through prioritizing the needs of a patient or patient group)
- Evaluation (reflecting on the care given) (Ignatavicius et al., 2018).
For expert nurses, the ability to prioritize based on these processes is predominately intuitive, and tasks are completed in a prioritized manner without much conscious thought. In unfamiliar situations, patient prioritization should be approached as a structured process, highlighting risk factors that may contribute to a decline in the patient’s condition and potential interventions that can reduce the risk of adverse outcomes (Jessee, 2019). Too often, a failure to recognize important patient data or an inability to interpret findings due to a foundational knowledge deficit can lead to adverse events, and the nurse may not realize the implications until it is too late. Failure to rescue or failure to recognize and act early during a patient decline can result in avoidable morbidity or mortality. Seasoned nurses are able to pull from their depth of knowledge and experience that allows them to act deductively and intuitively when prioritizing patient care. The novice nurse or one unfamiliar with a condition or patient situation has less experience to pull from and works from a more rigid knowledge base derived from textbook situations that may not mirror the current patient concerns. Practice and experience are the foundations of prioritizing patient care (Jessee, 2018).
Case Studies for Prioritization Practice
Case Study 1
Rachel is a medical-surgical nurse that has been practicing for two years in her unit. Today, she has been asked to work in the emergency department (ED) and has the following patients. In what order should she see the following patients, and why? (Answer key is below)
- A 10-year-old with a 2 cm laceration to her left arm. The laceration is bleeding through a 4 X 4 gauze every 5-10 minutes.
- A 21-year-old with complaints of a "migraine headache," vomiting, pain (9 out of 10), and unable to open their eyes due to light sensitivity.
- A 62-year-old male with COPD and increased difficulty breathing for the past two hours. His family reports a recent cold and significant worsening in the past 24 hours.
- A 45-year-old female with chest pain that is talking on her cell phone to her son as she is being checked in (Hargrove-Huttel & Colgrove, 2014).
Answer Key: Case Study 1
Rachel should see the patients in this order:
(c) A 62-year-old male with COPD and increased difficulty breathing for the past two hours. His family reports a recent cold and that he has been worsening significantly in the past 24 hours. This patient is a priority due to airway.
(d) A 45-year-old female with chest pain that is talking on her cell phone to her son as she is being checked in. This patient likely has an MI and care should be initiated before her condition declines.
(a) A 10-year-old with a 2 cm laceration to her left arm. The laceration is bleeding through a 4 X 4 gauze every 5-10 minutes. This patient would take priority over pain since she is bleeding, even if a small amount of bleeding.
(b) A 21-year-old with complaints of a "migraine headache," vomiting, pain (9 out of 10), and unable to open their eyes due to light sensitivity. While the patient is uncomfortable, this should not be life-threatening (Hargrove-Huttel & Colgrove, 2014).
Case Study 2
Jill is a travel nurse that went through a four-hour orientation to the unit she is working on today. She is receiving report on the six patients she will have for the shift. Which of the following actions should be a priority? (Answer key is at the end of the module)
- Ensure that she has access to the computer system and medication dispensing system on the unit.
- Develop a schedule for lunch and breaks in collaboration with the other staff.
- Request a bedside report rather than the current reporting system at this facility, since this is what she is used to.
- Ensure that she knows where the policy and procedure manual is located.
- Identify a contact person on the unit that can provide information if needed (Hargrove-Huttel & Colgrove, 2014).
Answer Key: Case Study 2
Jill’s priority should be ensuring access to the computer system and medication dispensing system on the unit in order to deliver proper care of her patients (a). The second priority would be to determine a contact person that can help with needed information (e), followed by the policy and procedure manual (d). Each of these can help her provide care for her patient assignment. Developing a schedule is a great way to organize for the day (b). It would be appropriate to ask for the bedside report, and if the nurses reporting are not opposed, then this style of hand-off can be utilized (c) (Hargrove-Huttel & Colgrove, 2014).
Case Study 3
Stacy has been a nurse for six months and was just released from orientation on her unit. She has seven patients today. The following reports were given about her patients. Which patient should she see first? (Answer key is below)
- A 42-year-old cholecystectomy patient that is four hours post-op and having uncontrolled pain.
- A 26-year-old newly diagnosed type 1 diabetic with a blood sugar of 320.
- A 19-year-old patient who attempted suicide with acetaminophen (Tylenol) last night and is being transferred to a psych unit this afternoon.
- An 82-year-old Alzheimer's patient with increased confusion and right-sided weakness that started approximately an hour ago.
- A 60-year-old female who had a myocardial infarction (MI) last night and is going to surgery in one hour (Hargrove-Huttel & Colgrove, 2014).
Answer Key: Case Study 3
Stacy should see the 82-year-old Alzheimer's patient with increased confusion and right-sided weakness that started approximately an hour ago (d). This patient may be experiencing a stroke and require immediate care. The MI patient (e) is already scheduled for surgery and is likely stable according to the report. While all of the patients need to be seen as soon as possible, this is the priority due to the limited window for interventions with potential stroke (Hargrove-Huttel & Colgrove, 2014).
Case Study 4
Kyle is on a four-week assignment at a level 1 trauma center as a CCU nurse. He is in his second week and feels comfortable with the unit and the staff. He has two patients. Patient A is a 46-year-old male who is 12 hours status-post-CABG and patient B is a 32-year-old female who had a motor-vehicle-accident (MVA) 36 hours ago and has multiple fractures and flail chest. Please place the following tasks related to their care in the most appropriate order. (Answer key is at the end of the module)
- Morning assessments.
- Administer PRN pain medication to patient B.
- Take report from the night nurse.
- Adjust patient A’s medications based on the doctor’s orders and the most recent set of lab results.
- Call the healthcare provider about patient B’s morning lab results.
- Review the medication administration record (MAR) and create a medication administration schedule for both patients.
- Empty the Jackson-Pratt (JP) drains in patient A's chest.
- Personal care (bath, oral care, and change clothing) for both patients (Lacharity et al., 2019).
Answer Key: Case Study 4
(c) Take report from the night nurse.
(a) Morning assessments.
(b) Administer PRN pain medication to patient B.
(e) Call the healthcare provider about patient B’s morning lab results.
(d) Adjust patient A’s medications based on the doctor’s orders and the most recent set of lab results.
(f) Review the MAR and create a medication administration schedule for both patients.
(g) Empty the JP drains in patient A's chest.
(h) Personal care (bath, oral care, and change clothing) for both patients.
It is important to obtain the report from the previous shift's nurse. This can be followed by a patient assessment to ensure the patient matches the report. Since patient B is having pain, it is important to address that prior to the other activities listed. Likely, the PRN pain medication would be administered during the morning assessment after ensuring there are no other reasons for the pain and that it is appropriate to give at this time. After this, the healthcare provider should be notified of patient B's labs to allow any medications or treatments to be adjusted. Most nurses create a schedule for medications at the start of their shift to avoid missing administration times. Unless patient A’s JP drains are full or leaking, they can wait to be emptied until the other activities have been done. Just prior to personal care is a good time to empty drains and assess wounds, while dressing changes are usually done immediately after personal care (Lacharity et al., 2019).
Case Study 5
Josh is working on a pediatric unit today and has six patients. He is working with a care team that includes an unlicensed assistive personnel (UAP), a licensed practical nurse (LPN), and a respiratory therapist (RT) on call. The following patients and diagnoses are assigned to him:
- A six-year-old returning from tonsillectomy needing PRN intramuscular (IM) or oral (PO) pain medication.
- A four-year-old with an asthma exacerbation needing their respiratory treatment.
- A 10-month-old who is post-surgery for pyloric stenosis needing a bath.
- A 12-year-old who had a four-wheeler accident two days ago resulting in a fractured femur and multiple wounds who needs a dressing change to a wound on their arm.
- A 14-year-old who is 12-hours post-appendectomy after a rupture complaining of nausea.
- A four-month-old with respiratory syncytial virus (RSV) needing their nose cleared of drainage (Lacharity et al., 2019).
Consider the following:
- Which patient(s) would be appropriate to delegate to the UAP?
- Which patient(s) would be appropriate to delegate to the LPN?
- Which patient(s) would be appropriate to call RT?
- Which patient should Josh see first, and why? (Answer key is at the end of the module)
Answer Key: Case Study 5
(1) The UAP can manage the bath for the ten-month-old (c). Using UAPs for personal care activities is appropriate delegation of duties.
(2) The LPN can manage the PRN pain medication that is either IM or PO for the six-year-old post-tonsillectomy patient (a), the 12-year-old needing a dressing change to the wound on their arm (d), and the four-month-old nose suctioning (f) (typically with a bulb syringe). If the pain medication was an intravenous medication, the LPN would not be able to administer in the majority of states. It is crucial to know the LPN scope of practice in the state that nurses are practicing in to avoid delegating tasks that are out of their scope of practice.
(3) The RT could be contacted to see if they are available to administer the respiratory treatment (b).
(4) Josh should see the 14-year-old complaining of nausea after surgery for a ruptured appendix (e) as the patient could be having a complication related to their surgery and should be fully assessed by the nurse quickly (Lacharity et al., 2019).
Case Study 6
Candace has been assigned to the neurology floor for the first time. She is typically a pediatric nurse. She is very nervous about this assignment as she is not accustomed to this type of patient. The charge nurse assigns her five patients and gives her a shift report on all five. Which of the following should be of greatest concern to Candace? (Answer key is at the end of the module)
- A 47-year-old female who had a brain aneurysm repair two days ago. She just arrived on the neuro unit from the ICU, and Candace was told in the shift report that she is stable with occasional reports of pain. She has an IV in the left antecubital with half-normal saline (0.45% NaCl) infusing and one in the right forearm that is heparin locked with flushes every shift. The UAP tells Candace that the patient is comfortable, but that her IV pump is "going off," and the bag of fluid looks low.
- A 33-year-old male who had a stroke and has a platelet level of 250,000 µ/L on his most recent set of labs. He is resting comfortably in bed, watching television. His morning medications are due, and his urinary catheter needs to be removed.
- A 26-year-old female who was admitted yesterday with an exacerbation of a seizure disorder. She had a valproic acid (Depakene) level of 75 µ/L this morning. She has not had her morning medications, including her valproic acid (Depakene), and is currently eating breakfast.
- A 52-year-old male with a brain tumor and a history of seizures, on phenytoin (Dilantin) with a current level of 28 mg/dL. He is asleep and has asked to be left alone.
- A 40-year-old female with multiple sclerosis (MS) receiving prednisone (Deltasone) IV. Her steroid dose was due one hour ago, but her IV needs to be restarted as it was pulled out overnight. She is currently in the shower with the assistance of a UAP.
(Lacharity et al., 2019)
What order should Candace see these patients in?
Answer Key: Case Study 6
Candace should be most concerned about the 52-year-old male with a phenytoin (Dilantin) level of 28 mg/dL, as a therapeutic level is 10-20 mg/dL, and this is significantly higher. Phenytoin (Dilantin) toxicity can have serious implications, and the healthcare provider should be notified ASAP. This should be the priority among this group of patients as all the other lab values and information is within normal limits.
She should see the patients in the following order:
(a) The 47-year-old female needing her IV checked to either replace the bag of fluid or troubleshoot why the alarm is sounding. This is a noisy annoyance that could indicate a potentially dangerous situation (an empty IV bag continuing to infuse), so Candace should quickly replace the bag of IV fluid before addressing her primary priority.
(d) The 52-year-old male with the elevated phenytoin (Dilantin) level to assess his condition prior to calling the healthcare provider.
(e) The 40-year-old female with MS to restart her IV and initiate her medication.
(b) The 33-year-old male to administer medications and discontinue his urinary catheter.
(c) The 26-year-old female with the valproic acid (Depakene) level of 75 µ/L, which is within normal limits for a morning assessment (Lacharity et al., 2019).
Case Study 7
John is an agency nurse who is assigned to an acute care unit in a long-term care facility. He receives a report on his patients for the day. Who should he assess first after receiving report?
- A resident with congestive heart failure (CHF) with 3+ pitting edema in their bilateral lower extremities.
- A resident with Parkinson’s disease (PD) that started hallucinating during the night and is sleeping now.
- A resident with Alzheimer’s disease (AD) that was wandering in the hallway at 2 am.
- A resident with terminal cancer who the UAP reported has lost eight pounds since their last weight check four weeks ago.
After John completes his morning assessments, he reviews the MAR and sees he has several medications to give. Which of the following medications should be given first, and why? (Answer key is at the end of the module)
- Acyclovir (Zovirax) for a resident with a diagnosis of Bell’s palsy.
- Cephalexin (Keflex) for a resident with a diagnosis of a urinary tract infection (UTI).
- Acetylsalicylic acid (Aspirin) for a resident with a diagnosis of cerebrovascular accident (CVA).
- Neostigmine (Prostigmin) for a resident with a diagnosis of MG (Lacharity et al., 2019).
Answer Key: Case Study 7
(b) The patient with PD who experienced hallucinations during the night should be seen first. This patient may be experiencing an adverse reaction to his PD medications. The other patients' symptoms are consistent with their conditions.
(a) The second patient to see would be the CHF patient, as 3+ pitting edema may require a medication adjustment, but this type of edema is expected with CHF.
(c) It is not abnormal for an AD patient to wander at night.
(d) Significant weight loss is expected with terminal cancer patients (Lacharity et al., 2019).
(d) Neostigmine (Prostigmin) promotes muscle function in patients that are diagnosed with MG. This medication should always be administered on time to prevent loss of muscle tone, especially the muscles of the upper respiratory tract. This would be the priority medication to administer at this time. The three remaining medications can be administered 30 minutes before or after their scheduled time without implications, so none of these are considered priority medications (Lacharity et al., 2019).
Case Study 8
Cindy just took a job as a home health nurse, and today is her first day off orientation. She has four patients to see. Which should she visit first, and why? (Answer key is at the end of the module)
- A patient with a new diagnosis of MS who stated to her husband that she wants to die.
- A patient with PD who is walking with a short, shuffling gait as reported by his wife.
- A patient with a recent C5 spinal cord injury whose mother reports redness and drainage at the Halo vest sites.
- A patient with a low back injury (L4) that called the office reporting a severe headache (Lacharity et al., 2019).
Answer Key: Case Study 8
(c) The patient with a recent C5 spinal cord injury reporting redness and drainage at the insertion sites of the Halo vest is the priority. The Halo vest is inserted into a bone and an infection around the insertion site can lead to osteomyelitis. This could become life-threatening and should be investigated immediately.
(d) The next priority would be the patient with a low back (L4) injury and complaining of severe headaches. This would be a more urgent concern if the spinal injury were higher, as it could indicate autonomic dysreflexia. However, at this level, it is less urgent and more likely represents a rebound headache due to pain medication or a slow spinal fluid leak.
(a) The MS patient who states she wants to die would be the next patient to see, yet not as urgent as the two back injuries.
(b) Finally, the PD patient with the shuffling gait is expected; this will require education for the patient and family regarding the disease process (Lacharity et al., 2019).
Case Study 9
Chris is a new nurse on the medical-surgical unit, and today is his first shift since completing his orientation. He is caring for a patient that weighs 425 pounds with MS who is minimally responsive. The UAP asks for assistance in moving the patient in the bed. Which of the following actions would be most appropriate? (Answer key is at the end of the module)
- Refuse to move the patient since their weight is this high.
- Tell the family that the patient will need to assist with repositioning in bed.
- Get another nurse or UAP to help move the patient in bed.
- Obtain a lifting device that will accommodate a patient of this weight (Lacharity et al., 2019).
Answer Key: Case Study 9
(d) It is important for Chris and his team to obtain a lifting device for a patient of this size as the opportunity for injury is very high. Since the patient is minimally responsive, they would not be able to help, and another person may not be enough help to turn the patient or move them without injury (Lacharity et al., 2019).
Case Study 10
Nurse Amy has an LPN and UAP on her care team to assist with patient care. Which of the following tasks would be appropriate to delegate to the LPN? Which would be appropriate to delegate to the UAP? (Answer key is at the end of the module)
- Assist a patient with MS to ambulate to the bathroom.
- Assess a newly admitted patient with pneumonia.
- Take the initial vital signs while administering a unit of blood to a patient.
- Administer a vitamin B12 injection to a patient with pernicious anemia (Lacharity et al., 2019).
While many of these seem simple, choosing the “next right move” or delegating appropriately can be difficult. Incorrect decisions by the nurse can lead to significant poor patient outcomes or even death. Upon arrival at the unit or point of care, nurses should identify and establish their care priorities, considering a rationale for each action taken in practice. They should identify and trend clinical data that is relevant to the patient's condition, as these are often precursors to impending changes in condition. The ability to prioritize is built on the knowledge of patient conditions and experience. The nurse must learn to differentiate between problems that must be attended to immediately, versus those that can wait. When in doubt, nurses should draw on supportive personnel that tasks can be delegated to as well as resources that are available in the workplace such as mentors, peers, or online resources (Jessee, 2019; Lacharity et al., 2019).
Answer Key: Case Study 10
(a) The UAP can assist the patient in ambulating to the bathroom.
(d) The LPN can administer the B12 injection to the patient with pernicious anemia.
(b, c) Amy will need to complete the admission assessment on the pneumonia patient and take the initial vital signs during blood administration. The LPN role in blood administration varies among states as well as institutions, but typically the RN must at minimum do the initial set of vital signs and hang the blood (Lacharity et al., 2019).
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