Nursing Priority Setting Framework - PDF

PRIORITY SETTING ​ Circulation FRAMEWORK. ​ Nutrition ​ Elimination ​ Fluid balance ​ Which client should I see first?...

PRIORITY SETTING ​ Circulation FRAMEWORK. ​ Nutrition ​ Elimination ​ Fluid balance ​ Which client should I see first? ​ Activity and exercise ​ What is the most important ​ Rest and sleep. assessment finding? ​ Which interventions should I provide now and​ which can be done later? ​ What is the proper sequence of Safety and Security Needs steps when​ ​ Living in safe environment performing a procedure? ​ Adequate income ​ What is the proper sequence of ​ Shelter from environmental​ interventions​ elements I need to take during an emergency situation? ​ Which situation poses an Love and Belonging Needs immediate risk to​ ​ Love client safety? ​ Affection ​ What tasks are most appropriate ​ Relationships for me​ to delegate? Involvement with community and spiritual groups help to meet this need. MASLOW’S HIERACHY OF NEEDS. Self Esteem Needs ​ Self respect ​ Personal worth ​ Social recognition Self-actualization Needs ​ Personal growth ​ Fulfilling own potential Maslow’s belief: Very few individuals reach this level. Physiological Needs ​ Oxygenation Client Care Focus ​ Most important: Assessment ​ Higher levels may compete with (data collection) first lower levels (depends on client ​ Evaluate client outcomes to situation) determine effectiveness of care ​ Maslow’s Hierarchy provides​ plan a framework ​ Consider all client factors before determining order Airway, Breathing, and Circulation ​ Priority of initial assessment NURSING PROCESS ​ Referred to as ABCs ​ All are critical to survival ​ Alteration in one could indicate threat to life/need for resuscitation Airway ​ Highest priority action ​ Must be open and clear Analysis (RN only) ​ Client might need: ​ Happens after nurse collects data ○​ Temporary oral or artificial ​ Second step of nursing process airway (tracheostomy or for RNs endotracheal tube) ​ Lays foundation for making ○​ Supplemental oxygen decisions about client's plan of care ​ Takes priority over planning, implementation, and evaluation Client Care Focus ​ Tool to determine priority of nursing actions ​ Each step based on decisions from previous step  ○​ Chemical and/or physical cardiac support ○​ Resuscitation ○​ Supplemental fluids (to re-establish intravascular fluid volume and blood pressure) Client Care Focus ​ Health care providers use ABC Breathing framework frequently ​ Second highest priority ​ Dictates order of care in ​ Essential for oxygen exchange: emergency situations and with unstable clients ​ Helps recognize early signs of ○​ Respiratory rate within complications expected reference range ○​ Adequate ventilatory effort Safety and Risk Reduction ​ Client might need: ​ Assigns priority to the factor or situation posing the greatest: ○​ Artificial ventilation ○​ Negative pressure gradient in ○​ Safety risk to the client pleural cavity ○​ Greatest risk to the client's ○​ Chest tube might re-establish physical or psychological negative pressure well-being ​ Multiple risks may require Circulation another priority setting ​ Third highest priority framework to identify risk posing ​ Heart rate and blood pressure greatest threat. within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion  ​ Risk posing immediate threat usually becomes the highest priority Client Care Focus ​ Assess for external factors ○​ Complete risk assessment ○​ Integrate interventions ○​ Assistive devices ​ Assess for internal factors Sources of Safety Issues ​ Client ○​ ABC combined with safety ​ Nurse and risk reduction ​ Provider ​ Medical equipment and environment ​ Home environment Least Restrictive/Least Invasive ​ Community ​ Priority goes to interventions that are least restrictive and least invasive to a client. Risk Reduction ​ Make sure it won't put the client ​ Types of risk at risk for harm or injury. ○​ External – Risks in client’s environment ○​ Internal – Laboratory values and vital signs outside expected reference range ​ Maslow’s Hierarchy or ABC priority setting framework to determine alteration posing greatest risk  Client Care Focus ​ Least restrictive interventions ○​ Close and constant supervision ○​ Assessing medications ○​ Bed and wheelchair alarms ○​ Mattress on floor next to client's bed ​ Least invasive interventions Least Restrictive ○​ Incontinent clients on bladder ​ Protects clients civil and legal routine rights ○​ Incentive ​ Unauthorized use of restraints spirometers/inhalation can be: treatments ○​ Oral or rectal administration of ○​ Assault and battery medications ○​ False imprisonment ​ Use least restrictive methods of​ restraining first. ​ Physical restraints only when ​ client, staff,​ or others' safety is at risk Least Invasive ​ Reduce number of organisms Emergent introduced into body to reduce ​ Class I – Life threatening injuries hospital acquired infections ​ Immediate treatment = chance ​ Reduce client infections to for survival reduce need for antibiotics ​ 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 Acute vs. Chronic extensive injuries ​ Acute needs may pose more of a ​ Do not pose a threat to life threat. ​ No threat to life even with ​ Chronic needs usually develop delayed treatment over period of time. ​ Attend to alteration in acute phase before they evolve into chronic alteration. Expectant ​ Class IV – Injuries are not Urgent vs. Nonurgent compatible with life ​ Urgent needs pose more threat​ ​ Potential for survival does not to client. exist, even with treatment ​ Needs become urgent when ​ Scare resources reserved for related to an intervention Classes I, II, and III. needed within a specified time. ​ When caring for a group of Client Care Focus clients, attend to the client with the most urgent need first. ​ Mass casualty situations when resources are scarce ​ Client least likely to survive = Unstable vs. Stable lowest priority ​ Unstable clients have needs that ​ Client with severe injuries (but pose threat to client’s survival. potential to survive with ​ Life-threatening needs often treatment) = highest priority involve airway, breathing, or circulatory status.  ​ Client at risk for becoming unstable are higher prioirty than clients who are stable. ​ Acute asthma vs. chronic emphysema ​ Urgent leaking sensation from abdominal wound vs. nonurgent pain medication request ​ Unstable potassium level vs. stable potassium level Client Care Focus ​ Select framework most applicable to the​ client situation ​ Also consider: ○​ Use of a second framework to help​ support first framework. ○​ Maslow's Hierarchy. ○​ Airway, breathing, and circulation​ framework (ABCs).