You are on page 1of 12




Nursing 4145: Holistic Nursing Care in Acute Illness II and End of Life Clinical
Learning Plan 4
Prioritization of care
High quality patient outcomes
Objective of the Course:
Upon successful completion of this course, the student will be able to:
1. Utilize the nursing process to create a plan of care for the complex patient.
Knowledge and skills leading to mastery of this competency:
a. Use clinical judgment and decision-making skills in appropriate, timely nursing care during
emergency situations.
b. Demonstrate the ability to set nursing care priorities for that group.
c. Interpret, prioritize and perform a sequence of nursing actions based on the patient needs
(nursing diagnoses, interventions, identified nursing actions and evaluation).
d. Evaluate effectiveness of the nursing actions identified in the care plan for a patient.
e. Recommend modifications to the nursing care plan for a patient.
f. Revise the plan of care based on an ongoing evaluation of patient outcomes.
2. Effectively communicate with members of the healthcare team.
Knowledge and skills leading to mastery of this competency:
a. Use written, verbal, non-verbal and emerging technology methods to communicate effectively.
c. Use inter- and intra professional communication and collaborative skills to deliver evidencebased, patient-centered care.
d. Communicate to nursing personnel the responsibilities for delegated actions.
4. Refine the ability to reflect on practice.
Knowledge and skills leading to mastery of this competency:
a. Create an intentional process to reflect on clinical reasoning and nursing experiences.
b. Engage in a reflective nursing practice to provide leadership in promoting advocacy,
collaboration and social justice.
c. Value the ideal of lifelong learning to support intentional reflection and excellence in nursing
d. Assume accountability for personal and professional behaviors.
e. Recognize the relationship between personal health, self-renewal, reflection and the ability to
deliver sustained quality care.

5. Manage and direct the care of the client with complex psychosocial and/or physiological
health needs.
Knowledge and skills leading to mastery of this competency:
d. Implement evidence-based nursing interventions as appropriate for managing the acute and
chronic care of patients and promoting health across the lifespan.
e. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions.
f. Facilitate patient-centered transitions of care, including discharge planning and ensuring the
caregivers knowledge of care requirements to promote safe care.
g. Provide nursing care based on evidence that contributes to safe and high quality patient
outcomes within healthcare microsystems.
h. Create a safe care environment that results in high quality patient outcomes.
i. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship.
j. Deliver compassionate, patient-centered, evidence-based care that respects patient and family
Priority setting begins when the nurse identifies and prioritizes a clients main diagnoses or
problems. Client problems must be ordered to determine preferential order for nursing actions.
Ranking in order of importance allows the nurse to focus on the clients most important needs
first and assist in organizing other care activities. Priorities must be established in relation to
importance (high, intermediate, or low) and time (initial, ongoing, and discharge). Appropriately
ordering priorities enables the nurse to meet a clients needs in a timely effective manner.
Clients must be involved in priority setting to ensure that the client and nurse concur with the
mutually agreed-on priority.
Learning Activities:
Prioritization exercise Handout 1
Prioritization of Cares Handout 2 (Activities 1 3)
Patient Outcomes Handout 3
Nurse Sensitive Indicators Handout 4
Come to class prepared to discuss:
o Prioritization of care
Client acuity
Availability of resources
Interruptions from care providers
Nurse-client relationship
Ward organization
Priority-setting strategies and frameworks
Philosophies and models of care

Experience and expertise of nurse

o High quality patient outcomes

o Reflective Journal
Learning Objectives
1. Apply quality improvement processes to effectively implement patient safety
initiatives and monitor performance measures, including nurse-sensitive
indicators in the microsystem of care.
2. Use improvement methods to design and test changes to continuously improve the
quality and safety of health care.
3. Reflect on ones own beliefs and values as they relate to professional practice.
4. Discuss the criteria use in priority setting.
5. Develop a plan of care from a nursing assessment
6. Identify the process of selecting nursing interventions
7. Explain how an activity diary (or log) helps you manage your time.
8. Describe how to set priorities based on your personal and professional goals.
9. Identify ways to organize your work to make the most of your time.

Handout 1
Prioritization Exercise
It is 15:00 and you report to work for the evening shift and are assigned three different patients.
1. Mr. Smith is a 56-year-old patient who was admitted to the hospital following a motor
vehicle accident. He suffered rib fractures and has a laceration along his left thigh. He has
a history of hypertension and gout.
Report from day shift: BP 148/90, HR 102, RR 24, T98.8, oxygen saturation 98%.
Lungs diminished to bases. Respirations shallow. Oxygen 2L via nasal cannula.
Chest pain with inspiration. Pain management with Morphine 4 mg every 4 hours,
last dose given three hours ago.
You have identified the following nursing diagnoses: ineffective breathing
pattern related to chest pain; acute pain related to musculoskeletal trauma; and
risk for infection related to open wound.
The patient is scheduled for a chest CT scan at 1600. He is complaining of pain 6
on a 0 10 scale. Ancef 1 gm IV due at 16:00. Patient has call light on and is
requesting to use bathroom.
2. Your second patient, Mrs. Johnson, is a 69-year-old female who had surgery yesterday
evening for a femoral fracture. She has a history of COPD, anemia, heart failure, and
hypertension. Her leg is in a cast.
Report from day shift: BP 136/82, HR 96, RR 18, T98.8. Oxygen saturation 92%
on 2L oxygen per nasal cannula. Lungs diminished throughout lung fields with
faint crackles to bases. Cast dry and intact. Foot swollen. CMS intact. Capillary
refill <3 seconds. Denies numbness or tingling to toes. Pain management with
Morphine PCA pump (continuous 1 mg/hr; PCA dose 0.5 mg every 10 minutes).
Patient used 12 mg total last shift.
Mrs. Johnsons nursing diagnoses include acute pain related to tissue swelling;
impaired mobility related to restricted movement form cast, excess fluid volume
related to compromised regulatory mechanism.
The patient is complaining of increased shortness of breath and presents with a
new cough. She is very anxious. Pain level 3 on 0 10 scale to leg. She knows
she is in the hospital but does not know why. The nursing assistant informs you
that she is attempting to get out of bed.
3. Your third patient, Mr. Parsons is a 36 year-old male who suffered a rotator cuff tear
playing baseball. He had surgery this morning. His right arm is elevated and in a sling.
Report from day shift: BP 142/92, HR96, RR12, T99.1. Oxygen saturation 98%
on RA. He has been anxious. Morphine 4 mg administered for pain at 14:30.
Lungs clear. CMS to right arm intact. Fingers warm to touch, without numbness
or tingling noted.

Mr. Parsons nursing diagnoses include: acute pain related to tissue swelling;
impaired physical mobility RT decreased muscle strength; Risk for infection
related to surgery.
Patient is sleeping on and off. Complaining of nausea. No vomiting noted. An
order for Zofran 4 mg IV push as needed if on the chart. The patient wants to go
home and is asking when he can have his discharge instructions.

Which patient will you see first and why?

Which diagnoses are high and which are intermediate priority?
Of the three clients, which one has greatest priority regarding pain management?
For each of the patients, prioritize the nursing interventions.

Handout 2
Prioritization of Cares
Activity 1: You are the nurse on a cardiac step-down unit. You have just received report on your
patients. You have been assigned the following patients. Which patient do you need to see first?
Second? Why?
Mr. Jones, a 53-year-old man admitted yesterday with angina pectoris. He is scheduled
for a cardiac stress test at 0830.
Mrs. Andrews, a 75-year-old woman who was transferred out of cardiac intensive care at
0530 today. She had uncomplicated coronary artery bypass graft surgery yesterday.
Mr. Walker, a 48-year-old man who experienced a myocardial infarction 1 day ago. He is
complaining of chest pain rates as a 6 on a scale of 0 to 10.
Mrs. Brandow, a 84-year-old woman who had a permanent pacemaker inserted yesterday.
She is complaining of incisional pain rates as a 4 on a scale of 0 to 10.
Activity 2: You are working in the triage area of an emergency room, and the following four
patients approach the triage desk at the same time List the order in which you will assess these
An ambulatory, dazed 22-year-old woman with a bandaged head wound.
An irritable infant with a fever, petechiae, and nuchal rigidity.
A 37-year-old jogger with a twisted ankle who has a pedal pulse and no deformity.
A 55-year-old woman with moderate abdominal pain and occasional vomiting.

Activity 3: You are the leader of a team caring for the following patients on a medical-surgical
unit. Your team includes yourself (an RN), a newly graduated RN who has recently
completed hospital orientation, and a nursing assistant. Your patients are as follows:
Ms. B, a 58-year-old woman with rheumatoid arthritis, underwent shoulder arthroplasty 3
days ago. She reports stiffness in her joints in the morning. Swelling is noted in bilateral
wrists and proximal interphalangeal joints.
Mr. D, a 37-year-old man with a history of kidney stones, reports severe back and flank
pain intermittently (rating 4 to 9 on a scale of 0 10). The night shift reports episodes of
nausea and vomiting. He has hematuria and dysuria. Mr. D. was admitted through the
emergency department at 23:00 last evening. He is using a patient-controlled analgesia
(PCA) pump.
Mr. A, an 19-year-old man, sustained a right tibial-fibula fracture in a car accident 8
hours ago. He has extensive skin abrasions underneath the case and on the right
anterolateral body. Obvious chest and abdominal trauma were ruled out in the emergency
department; however he is being monitored for occult trauma. He is receiving an
analgesic via PCA pump.
Mr. Z, a 30-year-old man, is currently in the operating room for an inguinal hernia repair.
He will return from the OR later in the shift.
Mrs. T, 1 67-year-old woman with end-stage multiple myeloma, is receiving palliative
pain management. The family is considering hospice care. She has been on the unit for 1
week. Her physician signed the DNR order 2 days ago.
Mr. M, a 53-year-old man, has been on the unit for 2 weeks, receiving IV antibiotics for
bacterial pneumonia. He has a history of IV drug abuse and chronic back pain and has
tested positive for HIV infection. It was reported that Mr. Ms oxygen saturation was
decreasing during the night shift.
You decide to do brief rounds on all the patients before shift report, to ensure safety and to help
determine acuity and assignments. List the order in which you should briefly check in on these

Handout 3
Patient Outcomes
Center for Medicare and Medicaid Services (CMS) Measures
Myocardial infarction (MI)

Aspirin given at arrival

Aspirin prescribed at discharge
Adult quit smoking cessation education
Beta blocker prescribed at discharge
Primary PCI within 90 minutes of arrival

Congestive Heart Failure (CHF)

Evaluation of LVS Function

Adult quit smoking cessation education
Discharge instructions covering:
Symptoms worsening
Weight monitoring

Pneumococcal vaccination given

Blood culture in ED prior to initial antibiotic
Adult quit smoking cessation education
Antibiotic given within 6 hours of arrival
Antibiotic selection
Influenza vaccination given


Surgical Infection Prevention

Antibiotic given within one hour of incision

Antibiotic selection
Antibiotic discontinued within 24 hours
Appropriate hair removal
VTE prophylaxis ordered with 24 hours
VTE prophylaxis timing give within 24 hours
Urinary catheter removed on post-op day 1 or post-op day 2
Beta blocker prior to admission and perioperative

Handout 4
Nurse Sensitive Indicators
1. Catheter associated urinary tract infections (CAUTI)
Properly secure
Assess daily for necessity of catheter
Not recommended to test balloon before insertion
2. Skin integrity and pressure ulcer prevention
Braden Scale on admission and daily
Skin inspection on admission, daily in acute care, and every 8 hours if Braden
score <12
3. Fall risk and fall prevention
Morse Fall Scale on admission, daily on day shift, and when condition changes,
when medication changes that could increase fall risk, upon transfer from one unit
to another, after a fall event has occurred.
4. Restraints
Discontinue when safe to do so
Nonviolent/medical justification
o Pulling at invasive lines or tubes and does not respond to verbal/nonverbal
o Impulsive behavior, poor safety judgment when other less restrictive
interventions/devices are ineffective
Violent/behavioral justification
o To manage violent or self-destructive behavior that jeopardizes the
immediate safety of the patient, staff, and others
5. Sepsis
Need to consider the signs and symptoms of sepsis


Known suspected infection AND 2 out of 4 of the following:

Temp >100.4 or < 96.8
WBC <4000 or > 12,000
HR >90
RR >20
PaCO2 <32
Lactic Acid < 4
SBP <90
MAP <65
Other considerations:
CAP Refill >3 seconds
Mental Status Changes
Low pH
HCO3 <19
UO <30cc/2hours
Sepsis Bundle used in ICU and ED
Sepsis 6 hour Bundle
Sepsis lab panel (Heme 1, CMP, PTT< INR, Lactic Acid)
Blood cultures prior to antibiotic
Antibiotic within 2 hours
Fluid resuscitation
Pressors for BP nor responding to fluids
Insertion of central line for pressor administration and refractory
Steroid with Levophed rates >5 mcg/min or multiple pressors
Sepsis 24 hour Bundle
Completion of 6 hour bundle
SVO2 level with Levophed rates >5 mcg/min
Glucose control monitoring and treatment to maintain BG<150
Measurement of CVP with septic shock


6. Ventilator Associated Pneumonia (VAP)

VAP Prevention Bundle
HOB >30 degrees
Daily DVT prophylaxis
Daily Stress ulcer disease (SUD) prophylaxis
Daily wean assessment
Daily sedation reduction/sedation vacation/wake-up trial
Oral care every 4 hours
7. Congestive Heart Failure (CHF)
VS: ICU every 1 hour; telemetry every 4 hours; Med-surg every shift
Cardiac Monitor: document every 4 hours and prn with changes,
Document: education
Saline lock
Labs: renal profile and BNP
Tests: CXR, EKG, ECHO if not done previously
Notify dietitian/cardiac diet,
Cardiac rehab
Smoking cessation
Activity per MD
Daily weights
Strict I & Os
o Medication reconciliation
o LVF assessment and ACE inhibitor or ARB (document if contraindicated)
o Activity
o Diet instructions
o Medication instructions
o Symptoms worsening
o Weight monitoring
8. Venous Thromboembolism (VTE)
DVT + PE = venous thromboembolism
o Calf/arm: pain, swelling, warmth, erythema/discoloration
o Respiratory: RR>20, dyspnea, HR>100, central chest pain
o DVT education handout given to high risk patients on admission
o Lovenox kit with patient education sheet
o Coumadin education sheet
PICC line routine care:


Measure arm circumference 4 inches above insertion site when line

inserted and with each dressing change. Compare measurement week-toweek.
9. Coronary Artery Disease (CAD)
o Assess for ASA on admission
o VS: ICU every 1 hour; telemetry every 4 hours if stable
o Cardiac monitor: document every 4 hours and prn with changes
o Document: education
o Saline lock
o Labs: troponin1 at 6 and 12 hours
o Notify: cardiac rehab, dietician, evaluated smoking/tobacco use
o Activity per MD
Discharge instructions:
Medication reconciliation
Aspirin at time of discharge
Beta blocker
ACE inhibitors or ARB (document if contraindicated)
Adult smoking cessation education