Priority Setting Frameworks

Client is experiencing unexpected manifestations w/ several body systems. Which framework should nurse use to prioritize client assessment?

ABCDE (NOT survival potential)

ABCDE

Airway: Stridor (obstructed airway): requires immediate medical attention Breathing: Circulation: assess capillary refill time, pulse (including volume and character) Disability: determine clients neurologic status Exposure: expose the client to check head to toe for unexpected findings

N is assessing using ABCDE approach: what is after airway and breathing assessments?

Blood pressure (circulation)

Using safety and risk reduction framework, which should N identify as priority?

Client reporting dizziness upon standing

N at providers office is reviewing records of several clients; which client is priority for treatment?

Client w/ new chest pain

Which client is priority for care?

Client who received digoxin and has heart rate of 48/min

N is caring for confused client who is trying to remove peripheral IV: what is least restrictive action?

Cover IV site with plastic bandage

N is assessing client using ABCDE priority-setting approach. Which actions should N take when completing "exposure" component?

Observe lower extremities for DVT Check for bruising Measure client's temp

Client reports feelings of inferiority and states they are not good enough. Which category of Maslow's Hierarchy of Needs?

Self-esteem

Triage

Tag clients based on injury severity Emergent (red): clients must be transported away immediately-life threatening injuries but high probability of survival (chest pain) Urgent/delayed (yellow): serious injuries that do not pose immediate threat to life (open fracture) Nonurgent/minimal (green): minor injuries "the walking wounded" Expectant (black): either deceased or not expected to survive (poor breathing, damage to multiple body systems)

N is providing education on priority setting frameworks: which statement should be made regarding safety/risk reduction?

This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being

Self-Esteem needs

Two factory motivate: the desire to feel good about oneself and having the respect of others (ex. body image)

Client has new onset of ab pain. Which category is the client's condition?

Urgent (not chronic, minimal or expectant)

Least restrictive/least invasive

Use least restrictive/invasive method to resolve a problem while maintaining client safety

Survival Potential Framework

Used in mass casualty situation: doing the most good for the maximum number of clients when resources are limited d/t large number of injuries

Extra

activities that are not essential to client care but can promote comfort (providing warm blanket)

Maslows Hierarchy of Needs

bottom (most important) to top (least vital) Physiological, safety, love, esteem, self-actualization

which client should nurse see first?

client with audible wheezing

Rationing/rationed care

d/t inadequate resources (time, staffing level, staffing mix), care is left undone, omitted, or missed (missed care is considered a med error)

priority setting

delivery of nursing care based on urgency or importance of client need

Self-actualization

desire for self-fulfillment: reaching ones greatest potential

N is admitting client w/hypertension. What should nurse do first?

perform physical assessment

Routine

tasks such as administering routine meds and performing required shift tasks

Critical

client care needs immediate nurse intervention to keep from deteriorating (respiratory difficulty, chest pain)

Urgent

client could suffer mild harm or discomfort if delay in addressing needs (postop pain)

Which client should nurse see first?

client receiving blood transfusion and reports urticaria (hives)

N is assisting w/ client triage at mass casualty event; which client should be first for transport?

client w/ ab wound and active bleeding

Physiological

essential physical needs required for survival: food, water, shelter, sleep, clothing, reproduction

Safety and risk reduction priority-setting framework

places priority on the situation or factor that places the client at the highest safety risk

Safety and security

security of the environment, personal security, employment security, health, property

Love and Belonging

social needs: involve feelings related to love and belonging (friendship, family, relationships, intimacy, trust, love, affection)