UNIT 1- PRIORITIZATION & CLINICAL REASONING Flashcards
Prioritization guide
- Emergency: ABCD and V&L (vitals and lab)
- Actual before potenital
- Systemic before local
- Most Stable -vs- unstable or least stable
- Acute before chronic
- Respond to trends -vs- isolated findings
- Maslow’s hierarchy
- Time managment
- Infecton control issue
- Clinical knowledge of procedural standards
What are the 3 levels of priority setting?
- ABCD V and L— (d is disability)
- 2nd- Mental status changes, untreated concerns, acute pain, acute elimination problmes, and imminent risks
- Especially if pain is unrelieved or elimination issues after procedures.
- 3rd- Health problems other than those at the first 2 levels such as other long-term issues in health, issues in health, issues in health education, rest, coping and so on.
Important to have a baseline on the patient to be able to determine a change in the patient to determine if things are better or worse
The first two examples must be treated before number three is addressed
What is A in ABCD and vitals and lab in emergencies and what do we need to know?
Airway
1. Assess for patent airway
2. Establish airway, if indicated
3. 3-5 minute window for oxygenation
Think “No air, No saving” … may need oral device.
What is B in ABCD vitals and labs and what do we need to know?
- Assess breathing and its effectivenes
- Intervene as appropriate.
My notes: Think about anything that might effect the breathing pattern
Once airway is established assess chest rise and fall, rate of breathing, skin color, o2, breath sounds, pattern, reposition
What is the C in ABCD vitals and labs…. and what do we need to know about it.
- Identify circulation concern
- Act as approriate to reverse circulatory problem
My notes: Assess pulse, EKG monitoring, cap refill, cold, cyanosis, color, numbness, tingling, pulse quality and assess what pt is reporting.
Important to figure out where the discoloration is and what it could indiate can tells us alot. Color can also be related to breathing
What is the D is ABCD vitals and labs and what do we need to know.
Disability
1. Assess for disability
2. Act to slow down development of disability— example vision changes related to HTN… if we can lower bp we can reduce vision changes….and progression to stroke
What do we need to know about actual problem vs. potential problem?
- This is when we need to look at the actual problem vs. a potential problem that could arise if not treated.
- Treat active issues first to be able to prevent further problems. Potential problems may never come if we are taking care of active problems.
MUST HAVE a recent assessment so you can identify new findings
What is actue problem vs. chornic problem and what do we need to know?
- Acute onset of problems are more serious than a chronic problem that a patient lives with each day
- Need to be thinking of all the potential issues that the may have going in the acute phase. What needs to be adressed first so that the patients condition does not worsen. Determine if there are new symptoms
- Chest pain and confusion are IMMEDIATE concerns
- Figure out if the new symptoms are cause for immediate concern…
- Some interventions may make them more at risk for potential problems.
What is trends vs. isolated findings and what do we need to know.
- Vital signs
- Pain Scale
- LOC
- GCS
Gradual change and deterioration are key. Someone continually having a rise or decline can indicate a serious issue. May need to match our interventions to our trends.
What do we need to know about systemic vs. local
- Life over limb..
Think. about this… broken arm… or not breathing… which would you fix first… obv. breathing… what good is a fixed arm with a dead patient.
What are the levels of maslow’s hiearchy of needs?
Level 1: Physiological- breathing, food, water, sex, sleep, homeostasis, excretion
Level 2: Safety: Security of body, of employemment, of resources, of morality, of the family, of health of property.
Level 3: Love/belonging: Freindship, family, sexual intamcay
Level 4: Esteem: Self-Esteem, confidence, achievement, respect of others, respect by others
Level 5: Self-actualization: Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
MUST KNOW.
What are some examples of priority words/statements?
- What action takes priority
- important to have a relevant assessment or do we need to get one. May need to ask family for information
- What should the nurse do FIRST
- What should the nurse do INITALLY
- What is ESSENTIAL for the nurse to do
Use Maslow’s hiearchy of needs, the ABCD’s of CPR and the steps of the nursing process
What do we need to know about orgnaizing workload?
- Time management
- Make a list, schedule blocks, priortize
- Use goal setting, delegation evaluate, analysis of what is going on
- ABCD will always take priority over time managment
- Must be flexible and adaptable and plan as we go.
- Infection control
- Clinical knowledge of procedural standards
What should we know about priortization based on acuity
- Identify the problems of each patient
- Review the active problems and goals
- Determine which patient problems are most urgent based on basic needs, the patients changing or unstable status, and complexity of the patients problem.
Ask ur self is what the patient is experiencing expected with the disease process? Is it concerning? Is it a red flag? has there been a change in status. How complex is the problem.
what is our clinical judgement in prioritization and clinical reasoning
- Recognize cues: What matters most?
- Analyze cues: what could it mean?
- Prioritize hypothesis: Where do I start?
- Generate solutions: What can I do?
- Take action: What will I do?
- Evaluate outcomes: Did it help?
