ATI: Priority Setting Frameworks

Client Care Focus (Summary)

Select framework most applicable to the client situation Also consider: use of a second framework to help support first framework Maslow's Hierarchy ABCs

4. Self-Esteem

Self respect Personal worth Social recognition

Maslow's Hierarchy of Needs

1. Physiological 2. Safety & Security 3. Love & Belonging 4. Self-Esteem 5. Self-Actualization

Nursing Process

1. Assessment First 2. Analysis 3. Planning 4. Implementation 5. Evaluation

ABCDE

A: Airway B: Breathing C: Circulation D: Disability E: Exposure A systematic method that can be utilized in any health care setting to evaluate and treat the client.

Client Care Focus (Additional Frameworks)

Acute asthma vs chronic emphysema Urgent leaking sensation from abdominal wound vs nonurgent pain medication request Unstable potassium level vs stable potassium level

Acute vs Chronic

Acute needs may pose more of a threat Chronic needs usually develop over period of time Attend to alteration in acute phase before they evolve into chronic alteration

A client reports a headache but states the need to speak with a dietician about their newly prescribed diet. A photo of a woman holding her head -Administer pain medication. -Initiate a referral for a dietician.

Administer pain medication.

Emergent

Class I - Life threatening injuries Immediate treatment = chance for survival Highest priority

Urgent

Class II - serious and extensive injuries Do not pose immediate threat to life Potential for survival even with delayed treatment

Nonurgent

Class III - less serious and less extensive injuries Do not pose a threat to life No threat to life even with delayed treatment

Expectant

Class IV - injuries are not compatible with life Potential for survival does not exist, even with treatment Scarce resources reserved for Classes I, II, III

Sources of Safety Issues

Client Nurse Provider Medical equipment and environment Home environment Community

Client Care Focus (Maslow's)

Higher levels may compete with lower levels (depends on client situation) Maslow's Hierarchy provides a framework Consider all client factors before determining order

A client requests help to ambulate to the bathroom, but states they feel like they're going to have an asthma attack. -Assist the client to ambulate to the bathroom. -Administer the client's inhaler to treat their asthma.

Administer the client's inhaler to treat their asthma.

Client Care Focus (Safety & Risk Reduction)

Assess for external factors: complete risk assessment, integrate interventions, assistive devices Assess for internal factors: ABC combined with safety and risk reduction

1. Assessment

LPN does data collection and lets the RN know pertinent information

3. Planning

3rd step RN 2nd step LPN establish outcomes and plan of care

A nurse is caring for a client who has asthma. Which of the following actions should the nurse identify as the priority? A Auscultate lung sounds B Check blood pressure C Compare bilateral radial pulses D Determine capillary refill

Auscultate lung sounds (The nurse should monitor the client's blood pressure, check bilateral radial pulses, and determine capillary refill to assess circulatory status; however, auscultating the lung sounds for a client who has asthma is the priority.)

Survival Potential

Chance client has for survival during mass casualty event Appropriate use of resources to save greatest number of lives Different from civilian triage system in emergency departmets

Client Care Focus (Least Restrictive/Least Invasive)

Least restrictive interventions: close and constant supervision, assessing medications, bed and wheelchair alarms, mattress on floor next to client's bed Least invasive intervention: incontinent clients on bladder routine, incentive spirometers/inhalation treatments, oral or rectal administration of medications

4. Implementation

4th step RN 3rd step LPN interventions for health

5. Evaluation

5th step RN 4th step LPN in process or completed

A nurse is assisting with mass-casualty triage of clients following a gas explosion. Which of the following clients should the nurse recommend for priority treatment? A A client who is unable to walk, has burns on both legs, and reports hurting too much to move B A client who has a metal rod penetrating the forearm C A client who has a small laceration on his forehead, and is walking around aimlessly D A client who has no spontaneous breathing

A client who is unable to walk, has burns on both legs, and reports hurting too much to move

In the video the nurse is receiving change of shift report on a group of clients. If you were the nurse in this scenario, which of the following clients would you see first? A Nancy Jones, who has an infiltrated IV line and has an IV medication scheduled B Justin Foster, who requested pain medication that has not yet been administered C Anna Chen, who requested assistance to the bathroom and an AP was notified D Lenny Williams, who reports pain in his calf and has localized redness of the area.

Lenny Williams, who reports pain in his calf and has localized redness of the area.

2. Safety & Security

Living in safe environment Adequate income Shelter from environmental elements

3. Love & Belonging

Love Affection Relationships Involvement with community and spiritual groups help to meet this need.

Client Care Focus (Survival Potential)

Mass casualty situations when resources are scarce Client least likely to survive = lowest priority Client with severe injuries (but potential to survive with treatment) = highest priority

1. Physiological

Oxygentation Circulation Nutrition Elimination Fluid Balance Activity & Exercise Rest & Sleep

5. Self-Actualization

Personal growth Fulfilling own potential Maslow's belief: very few individuals reach this level

Least Restrictive/Least Invasive

Priority goes to interventions that are least restrictive and least invasive to a client Make sure it won't put the client at risk for harm or injury

Additional Priority Setting Frameworks

Priority goes to: Acute over chronic alterations in health Urgent over nonurgent needs Unstable over stable clients

Least Restrictive

Protects clients civil and legal rights Unauthorized use of restraints can be: assault and batter, false imprisonment Use least restrictive methods of restraining first Physical restraints only when the client, staff, or others' safety is at risk

A client reports being hungry and is concerned about paying for their hospital bill. -Provide the client with a snack. -Contact the hospital's social services department.

Provide the client with a snack.

2. Analysis

RN only happens after nurse collects data second step of nursing process for RNs lays foundation for making decisions about client's plan of care takes priority over planning, implementation, and evaluation

An AP reports that an adult client has a blood pressure of 90/50 mm Hg, is feeling dizzy, and has a respiratory rate of 18/min. -Recheck the client's blood pressure. -Listen to the client's lung sounds.

Recheck the client's blood pressure.

Least Invasive

Reduce number of organisms introduced into body to reduce hospital acquired infections Reduce client infections to reduce need for antibiotics

A client was admitted to a medical-surgical unit at 0900. The client reported experiencing abdominal pain during the night, which was unrelieved after taking oral pain medication prescribed by the provider. A family member transported the client to the emergency department (ED). The client received IV morphine in the ED and was admitted to the medical-surgical unit for further workup of the abdominal pain. After completing an initial admission assessment, the nurse left the room to discuss the client's plan of care with the attending provider. Upon returning to the client's room several minutes later, the nurse observes that a visitor is with the client. The visitor pulls the nurse aside, stating, "There is something wrong with my friend. She keeps referring to me as her brother, but her brother passed away many years ago. She also thinks that I have come to visit her at her home." How should the nurse categorize the client's needs at this time using urgent versus nonurgent categorization?

The nurse should categorize a change in neurologic status as an urgent need. Clients who are experiencing respiratory difficulty, chest pain, or a change in neurologic status are prioritized as urgent. The nurse should collect further client data and report this finding.

Risk Reduction

Types of Risk: external- risks in client's environment; internal- lab values and VS outside their normal Use Maslow's Hierachy or ABC to determine greatest risk Risk posing immediate threat usually becomes highest priority

Unstable vs Stable

Unstable clients have needs that pose threat to client's survival Life-threatening needs often involve ABCs Client at risk for becoming unstable are higher priority than clients who are stable

Urgent vs Nonurgent

Urgent needs pose more threat to client Needs become urgent when related to an intervention needed within a specified time When caring for a group of clients, attend to the client with the most urgent need first

The nurse has identified that they should see Lenny Williams first. Which of the following is the priority framework that the nurse used to support this decision? A Nursing process B ABCs C Urgent vs nonurgent D Acute vs chronic

Urgent vs nonurgent (This framework is used to analyze a set of findings and determine which are urgent and which are nonurgent. When using the urgent vs nonurgent approach to client care, the nurse determines that the priority finding received in report is the pain and localized redness in Lenny Williams's calf. )

Safety & Risk Reduction

assigns priority to the factor or situation posing the greatest: safety risk to the client, greatest risk to the client's physical or psychological well-being multiple risks may require another priority setting framework to identify risk posing greatest threat

2.Breathing

essential for oxygen exchange: respiratory rate with expected reference range, adequate ventilatory effort client might need: artificial ventilation, negative pressure gradient in pleural cavity, chest tube might re-establish negative pressure

3.Circulation

heart rate and blood pressure within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion client might need: chemical and/or physical cardiac support, resuscitation, supplemental fluids (to re-establish intravascular fluid volume and blood pressure)

1. Airway

highest priority action must be open and clear client might need: temporary oral or artificial airway (tracheostomy or endotracheal tude), supplemental oxygen

4.Disability

measuring disability involves determining a client's neurologic status. This includes the client's level of consciousness, response to verbal or painful stimulation, and level of orientation.

5. Exposure

to complete this step, the nurse should uncover the client as needed to check the client from head to toe, while maintaining privacy and body temperature, and observing for any unexpected findings.

Client Care Focus (Nursing Process)

tool to determine priority of nursing actions each step based on decisions from previous step most important: assessment (data collection) first evaluate client outcomes to determine effectiveness of care plan