Fundamentals - Leadership, part 2: Patient Prioritization
by Meris Shuwarger November 24, 2022 Updated: August 10, 2023 10 min read
- 0:00 What to Expect in Patient Prioritization
- 00:22 Patient Prioritization teaching
- 12:35 Quiz on Patient Prioritization
Hi. I'm Meris, and in this video, we're going to be talking about patient prioritization. I will be following along using the leadership flashcards, which are available in our Fundamentals of Nursing flashcard deck, so if you have those, I would strongly encourage you to go ahead and pull those out so that you can follow along with me. All right. If you're ready, let's go ahead and get started.
Now, if you are in nursing school, you are probably very familiar with patient prioritization questions, and if you are working as a nurse, then you are probably familiar with how to prioritize patient care, but let's review some of the models of patient prioritization. So I'm going to start with the first card here, which covers three different models. We're going to talk about the nursing process, Maslow's hierarchy of needs, and then the ABC setting priority.
Nursing process. This is a way of thinking, a way of guiding our thought that allows us to think in sequential steps all the way from the assessment into the diagnosis, the planning, the implementation, and the evaluation. You probably learned ADPIE in your very first nursing school class because it's that important. And when you are taking your nursing school exams, it is important that you look at the options provided to you in the test questions and see where do they fall in the nursing process. For instance, if we say, "I have a patient who's having difficulty breathing," there's going to be a bunch of options. What should you do first? I can't jump to just slapping some oxygen on them and calling the doctor if I haven't assessed them first. I need to assess. Are they having difficulty breathing because they just need to cough something up? Are they having difficulty breathing because they're laying supine, and I can just sit them up? What's going on? Or if I assess and I say, "Oh my God. We have absent breath sounds on the left side," there's a very different implementation for that than the patient who just needs to sit up. So always, always we're thinking about the nursing process. We're going in that order. We assess, diagnose, plan, implement, and evaluate.
Some key words I want you to think of when you are in that test-taking environment. Assess. They might just tell you. They could give you some things that are assessment tools, like obtaining vital signs. Right? Listening to breath sounds. All of those are part of the assessment phase. Now, when we are talking about diagnosis, that's kind of where we're getting into that nursing diagnosis of, "What do I think is going on?" Planning, though, that's like, "What should we be doing for this patient?" So you might think about goal setting here, in this step. We might be thinking about discharge planning. Anything like that is going to fall under the planning phase. Now, implementation is anything you are doing to or for the patient: putting on oxygen, administering medication, starting a Foley catheter. All of those are part of the implementation stage. And evaluation is kind of the same as assessment, except you are assessing how your implementations worked. So you might see the word assess in there, but it's going to give you something like, "Assess the patient response to oxygen." That is evaluation. So very important to understand those steps.
Now let's talk about Maslow's hierarchy of needs. Maslow came up with this hierarchy of needs. You have seen it. It's the pyramid. And the idea here is I cannot worry about things at the top of this pyramid if the bottom of the pyramid has not been built for me. I can't build a house if there's no foundation. So what does that mean? It means that your patient's most basic fundamental physiological needs need to be met before we can worry about things like safety and security or psychological needs of love and belonging, self-actualization. I can't worry about that stuff if I'm concerned about the fact that I'm hungry and thirsty and I don't have shelter. Those things must come first. And this applies to nursing test questions as well. So for instance, when prioritizing a nursing diagnosis for a patient with anorexia nervosa, we need to be concerned about the physiological issue at play here before I can worry about the psychological issue. So I need to make sure that my patient isn't at risk for some kind of complication because of their malnutrition. I need to treat the dehydration, electrolyte imbalances. Anything like that needs to come first before we can work on the rest. Same thing if my patient is in severe pain. I can't really do a great psychosocial evaluation of my patient because they're not worried about telling you about how they're doing at home and things like that when I am in 10 out of 10 worst pain of my life. So we're always thinking about, "Have my patient's basic needs been met?" If so, then I can move on to the other things. If not, we need to address those.
And then, of course, there's everybody's favorite, the ABC setting priority. ABCs. You'd better know them by now. Airway, breathing, and circulation. In that order, except for when we are talking about CPR. Now airway, breathing, and circulation, it can feel counterintuitive sometimes. For instance, if I tell you that you have a patient who is experiencing an acute asthma attack, and they have inspiratory and expiratory wheezes, they're 91% on room air, and then you also have a patient who has 10 out of 10 crushing chest pain, you might feel like you should prioritize the chest pain patient. But according to the ABC setting priority, the patient with the breathing issue which is actively compromising them - they're having wheezes, and their pulse ox is dropping - they are the priority. Okay? So always, always, always if you are in a test situation, if you are in clinical practice, whatever you're doing, stop and ask yourself, "Is this a threat to my patient's airway, their breathing, or their circulation?" Let me give you an example, too, of an airway threat. If I have a patient whose Glasgow Coma Scale is less than 8, they cannot protect their own airway. If I have a patient who is having stridor, that high-pitched-- that sound. Very scary, first of all. That is my least favorite sound as a nurse. But that's a threat to my airway. If I have a patient who is having anaphylaxis and their airway is closing up, that is a threat to the airway. Breathing is stuff like the moving of air. Right? That's your asthma patient. That's the patient with COPD. Circulation is going to be things like bleeding, any kind of impaired circulation like peripheral artery disease, something along those lines. That is your ABC setting priority framework.
Next up, we're talking about how to set priority in a couple of different ways. We're going to be going over acute versus chronic and unexpected versus expected. Now, acute versus chronic. The acute concern should take priority over the chronic concern. And what does this mean? So let's say I have a patient with asthma and I have a patient with COPD. They present to the emergency room, and the patient with COPD, they're having some difficulty breathing, but they kind of say, "This is sort of my baseline. I just feel like it's a little bit harder to breathe," and they're SATing 92% on room air. And then I have my patient with asthma who's here for an acute asthma attack, and they say, "I've taken my inhaler three times. I can't get relief. It's so tight. I'm feeling dizzy." Right? They're having an acute exacerbation of their asthma, and this is the thing that is going to kill my patient fastest. When in doubt for setting priority, ask yourself, "Who is going to die the soonest? What is going to kill my patient the fastest?" The COPD, absolutely my patient can become very sick, very ill, and die from a COPD exacerbation, a CHF exacerbation. My patient with asthma, though, who is having the acute asthma attack right now, they will die right now if I don't intervene. So acute versus chronic.
Now, unexpected versus expected findings. So unexpected findings are always going to take priority. So for instance, if I tell you I've got two patients with CHF, right, two patients in congestive heart failure, and one of them has 1+ pitting edema, they have some jugular venous distention, but they're 93% on room air. Then I have another patient with CHF, and they have unilateral leg swelling. They have pain in the back of their leg in their calf. It's red. That is unexpected for CHF. Right? That is not an expected finding for this patient. Whereas a patient having 1+ pitting edema and a little bit of JVD, that's expected for a CHF patient. Or if we're talking about complications related to that patient's condition. If I have two patients with CHF, one is stable, and one tells me that they're having sudden-onset difficulty breathing, I listen to their lungs. They have copious crackles in their lungs. That's unexpected for their day-to-day life. That is the threat to my patient's health and safety, and that is going to take priority over the patient with the more stable, expected findings.
Okay. And lastly, we're going to talk about two other ways to set priority. The first one is restrictive or invasive procedures. So we always start from the least restrictive or invasive thing, and we work up progressively to the most restrictive or invasive. So for instance, if I have a patient who is having acute urinary retention, I'm not just going to slap a Foley in them. Right? That is very invasive. It could lead to infection. That's not going to be where I should be going first. We might try some things like we could do turning on the faucet while the patient tries to use the bathroom. We could use warm water poured over the perineum to help stimulate urination. Then maybe we're moving up to medications to try and stimulate my patient to urinate. Then if that doesn't work, maybe we're going to a straight catheter, and if that still doesn't fix the issue, now maybe we're talking about a Foley catheter before further intervention. Same thing for patients who are experiencing a need for restraint in some way. We're not just going to jump to four-point locking restraints. We're going to start with de-escalation techniques. We're going to try to calm the patient down. Maybe we'll try to move the patient closer to the nurse's station, arrange for a sitter before we ever move on to things like restraints, and then when we do, we're going to start with the least restrictive before we go on to the most restrictive.
Now the last way of setting priority that I want to talk about, and we'll talk about this more in community, but survivability potential. In the hospital setting, you are always going to prioritize the sickest person. Right? If that person has no pulse, they're the sickest person. If the person has a penetrating head wound, oh my gosh, they're the sickest person. But if we have a mass-casualty incident, the ethics of care change, and my job now is to provide the most care that will provide the most good to the most people, so this means that I'm going to prioritize patients who are more likely to survive. This is not your typical triage. This is not what we do in the emergency room. This is not how healthcare normally functions, but if we are talking about mass-casualty incident triage, we do not prioritize people who are already dead or close to death. So the patient with the penetrating head wound, the patient with a Glasgow Coma Scale of 3, the patient who is pulseless, the patient with agonal breathing, all of those are big red flags for, "This patient is dead or close to dead and unlikely to survive even with medical intervention." They are the lowest priority. The patients who are the highest priority are the ones who are the sickest but most likely to survive. The open femur fracture. The patient with a sucking chest wound. All of those patients are more likely to survive, and we're going to prioritize them. Then we'll move on to things that are serious but not imminently deadly, like the broken arm or a burn on the limb or something like that. And then we will move down to what we call the walking wounded, so this is someone who maybe they have a big scrape, or they've broken a finger or something like that. They need treatment, but they're not going to die anytime soon. They can wait a little bit. Again, we have mass casualty. There are dozens, hundreds of people who are sick or injured. This is when we are going to use this type of patient prioritization.
Okay. That is it for patient prioritization. I hope you learned something in this video. Please comment and let me know something that you learned that you may not have known before because I think it's a really great thing to tell other people that it's okay to not know everything all of the time. Before you go, I want to make sure that you can test your knowledge using some of my quick review quiz questions. All right. Here they are. Okay. Are you ready to test your knowledge? Here we go. According to Maslow's hierarchy of needs, which patient concern would take priority, imbalanced nutrition or disturbed body image? Imbalanced nutrition would take priority as this is a physiological issue. Which patient should the nurse prioritize, a patient with CHF exhibiting 1+ pitting edema or a patient reporting new-onset leg pain and swelling? The patient with new-onset leg pain and swelling should be prioritized. 1+ pitting edema in a patient with CHF is an expected finding. When performing mass-casualty triage, which patient should the nurse prioritize, an unresponsive patient with a penetrating head wound or a patient with a sucking chest wound? The patient with the sucking chest wound should be given priority as they are more likely to survive than the patient with the penetrating head wound.
All right. That is it for this video. I hope you learned something. Leave me a comment about something you learned or experience about leadership styles or patient priority setting. I'm excited to hear. Thanks so much, and happy studying.
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