NUR 4113 Module 2 Prioritization Analysis Example

Four Patients, One Admission and a BiPAP Alarm at 0715: Prioritizing a Heavy Progressive Care Assignment on an Unfamiliar Unit With Urgency, Importance and the ABCs

Student Name

American College of Education

NUR4113: The Adaptable Travel Nurse Advantage

Module 2 Assignment

Instructor Name

March 12, 2029

What Priority Setting Is

Hendry and Walker (2004), reviewing the literature on priority setting in clinical nursing, define it as ordering nursing problems using notions of urgency and importance to establish a preferential order for nursing actions, and note that the skill is difficult for newly qualified nurses to acquire and is influenced by the nurse's expertise, the patient's condition, the resources available and how the ward is organized. A traveler on an unfamiliar unit is not a new graduate, but several of those influences change at once: the resources, the organization of the unit and the nurse's familiarity with its patients. This paper applies an urgency and importance approach, with the airway, breathing and circulation sequence used to break ties among urgent problems, to one assignment on my third shift.

The Assignment at 0700

Patient A, 71, is on bilevel noninvasive ventilation for a chronic obstructive pulmonary disease exacerbation; the night nurse reports he was more drowsy at 0500 and his morning blood gas is pending. Patient B, 64, has atrial fibrillation with rapid ventricular response on a titrated diltiazem infusion; his heart rate is 112 and the order allows titration every 15 minutes to a target below 110. Patient C, 58, is one day after a bowel resection on a heparin infusion, with a partial thromboplastin time due at 0800 and a nomogram adjustment to follow. Patient D, 80, is medically ready for discharge home this afternoon after heart failure treatment and needs teaching about daily weights and a new diuretic dose. An admission from the emergency department, a patient with a gastrointestinal bleed, is expected by 0900. At 0715, as I finish report, Patient A's ventilator alarms for a low tidal volume.

Ordering the Patients

Patient A comes first, now. A low tidal volume alarm in a drowsy patient with an exacerbation of lung disease is an airway and breathing problem that is both urgent and important: it may mean a mask leak, but it may mean worsening hypercapnia, which would explain the drowsiness. I go to him before anything else, check the mask fit, his level of consciousness, respiratory rate and pattern and oxygen saturation, and call respiratory therapy. If he cannot be roused easily, I call the rapid response team, using the number on my pocket card from orientation.

Patient B comes second, within the next 15 minutes. His rate is only slightly above target, he is not reported to be symptomatic and titration is a circulation priority that is urgent but not immediately dangerous. Patient C comes third, at 0800, because the laboratory draw and heparin adjustment are important and time-specific but not yet urgent. The admission, when it arrives, will need a prompt assessment for signs of bleeding and hemodynamic instability, which may place it above Patient B at that time. Patient D is important but least urgent: discharge teaching matters for preventing readmission, and it will be scheduled for late morning when the unit is calmer. Urgency decides who I see in the next five minutes; importance decides who I must not let slip through the whole shift.

Why Patient A Outranks the Titration

Placing a patient on noninvasive ventilation ahead of a patient on a titrated cardiac infusion may look counterintuitive, since the infusion is the more obviously high-alert therapy. The reasoning rests on what each patient's trajectory could be in the next hour. Patient B's heart rate is two beats above target on a drug that is working; a delay of fifteen minutes in titration carries little risk. Patient A's increasing drowsiness on noninvasive ventilation may be a sign that ventilation is failing and that carbon dioxide is rising, a situation that can progress to respiratory arrest. The British Thoracic Society and Intensive Care Society guideline on ventilatory management of acute hypercapnic respiratory failure emphasizes close monitoring after noninvasive ventilation is started, with repeat blood gases, and a plan agreed in advance for what will happen if it fails, including whether the patient is a candidate for intubation (Davidson et al., 2016). That makes Patient A's escalation plan part of the first assessment: I need to know from the chart or the provider whether he is for intubation and intensive care, because the answer determines whom I call if his blood gas worsens. On an unfamiliar unit, I cannot assume that this has been decided or documented where I would expect to find it, so I will check directly at 0720.

Time Plan and Delegation

After Patient A is stable, the plan runs as follows: 0730 assess and titrate Patient B and set a timer for the next titration; 0745 first assessments of Patients C and D; 0800 draw or confirm Patient C's laboratory sample; 0815 to 0845 morning medications in order of time sensitivity, starting with Patient B's scheduled rate-control drug; 0900 receive the admission; 1100 discharge teaching for Patient D with his daughter present. I will delegate vital signs for Patients C and D, Patient D's morning weight and hygiene care to the nursing assistant, stating which values to report immediately, such as a systolic pressure below 90 or a heart rate above 120. On an unfamiliar unit, I will also tell the charge nurse at 0730 that Patient A may need a higher level of care, so that if the admission arrives while I am managing him, someone else can begin its intake.

Reprioritizing at 0900

At 0900, Patient A's blood gas returns with a pH of 7.28 and a carbon dioxide level of 68, higher than at admission, and he is harder to rouse. At the same moment, the admission arrives. The priority is clear: Patient A may need intubation and transfer to intensive care, and he needs me at the bedside while the rapid response team is called. I ask the charge nurse to receive the admission, which I had anticipated at 0730, and ask a neighboring nurse to watch Patient B's heart rate while I am occupied. Patient C's heparin adjustment, due after the 0800 result, is delayed by 20 minutes and I tell the charge nurse so. Kalisch et al. (2009), analyzing the concept of missed nursing care, describe how competing demands force decisions about priorities and lead to care that is delayed or omitted; the answer on an unfamiliar unit is to make the delay visible to someone who can help, rather than hoping it goes unnoticed.

What the Unfamiliar Unit Added

Every decision above would be the same on my home unit, but each took longer here. I did not know the respiratory therapist's number by heart, the ventilator was a model I had used only twice and I did not know which nurses were likely to have capacity to help. The prioritization framework does not change on a new unit; what changes is the time each action takes and the number of things I have to ask. The practical lesson is to front-load the questions, identifying at the start of each shift who can help with what, and to lower my threshold for asking the charge nurse to redistribute work, because my usual speed is not available to me in the first weeks of a contract.

References

Davidson, A. C., Banham, S., Elliott, M., Kennedy, D., Gelder, C., Glossop, A., Church, A. C., Creagh-Brown, B., Dodd, J. W., Felton, T., Foëx, B., Mansfield, L., McDonnell, L., Parker, R., Patterson, C. M., Sovani, M., & Thomas, L. (2016). BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax, 71(Suppl. 2), ii1-ii35. https://doi.org/10.1136/thoraxjnl-2015-208209

Hendry, C., & Walker, A. (2004). Priority setting in clinical nursing practice: Literature review. Journal of Advanced Nursing, 47(4), 427-436. https://doi.org/10.1111/j.1365-2648.2004.03120.x

Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x