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Running head: PRIORITY NURSING CARE

Priority Nursing
Davinder Bassi
XXX XXX XXX
NURS 252
Professor X
March 31, 2015
Humber ITAL

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Becoming a nurse is about more than learning technical skills and competencies. As the
population ages, clients are often presenting with multiple comorbidities. To provide them with
the best possible outcome and the least amount of harm, nurses must also learn to prioritize their
clients problems (CNO, Professional Standards, 2009). This involves developing criticalthinking, problem-solving, and decision-making skills in order to interpret a clients greatest
needs in the least amount of time. This paper will present a case scenario; discuss its nursing
priority, defend the priority clinical manifestation, and provide nursing interventions with
evidence-based rationale.
Case
A 64 year old female resident in long-term care (LTC) with type 2 diabetes; coronary
artery disease with coronary artery bypass graft 4 years ago; atrial fibrillation; hypertension; and
depression. Her chief complaint consists of a UCP reporting CBG at 12.6; resident refusing
meals and medications; refusing to interact with other residents or engage in social activities;
refuses vital signs to be done; resident states Leave me alone! UCP mentions resident tried to
give UCP her favourite bracelet.
Nursing Priority
Although the resident has multiple pathophysiological issues, her priority is one of
psychosocial concern. The resident is exhibiting self-harm behaviours through neglect by
refusing to eat, drink or take her medications (Osgood & Brant, 1990). She also presents with
multiple suicidal risk factors. Firstly, she is a resident of LTC for an unknown length of time.
Sakinofsky (2014) found suicide prevalence to be highest in hospitals but still relatively high in
LTC facilities. Jancin (2014) states the transition to a nursing home is a period of high risk for
suicide among the elderly (p. 16). The move to LTC may have been initiated due to sickness,
physical decline, or loss of spouse, therefore, adjusting is stressful and involves a degree of
loss (Podgorski, Langford, Pearson & Conwell, 2010, p.1). Secondly, the resident is at higher

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risk of self-harm because she presents with one of the most significant risk factors of having
depression (Touhy, Jett, Boscart, & McCleary, 2012). Early on after her move to LTC, this
resident needed a depression assessment to assess for suicidal thoughts and ideations (Touhy et
al., 2012). Lastly, other risk factors found to be common among seniors are hopelessness and
functional impairment (Podgorski et al., 2010). Hopelessness is evident with this resident when
she does not allow any care to be performed (including her vital signs), and withdraws from
other residents, as well as group activities. Each of these risk factors puts the resident at
immediate risk of self-harm, thus it is the chosen nursing priority.
Clinical Manifestation
The most urgent clinical manifestation for this resident is that she is trying to give away
her favourite bracelet to the UCP. This is considered a critical warning sign of a suicidal
individual and should be taken very seriously (Touhy et al., 2012; Wood et al., 2011). Other selfharmful behavioural clues this resident displayed were a refusal to interact with other
residents; taking unnecessary risks by refusing medication for her chronic conditions; displaying
personality changes by yelling leave me alone! to the UCP and, finally, showing a loss of
interest in her favourite activities by not participating in LTC social events (Wood et al., 2011).
This social withdrawal, loss of initiative, and loss of appetite are also indicative of suicidal
warning signs (Potter & Perry, 2010). Giving away her prized possession, coupled with other
serious risk factors, such as, depression shows the resident is getting her affairs in order as she
prepares for imminent death. Recognizing this manifestation as soon as possible is the first step
to protecting the resident from any possible self-inflicted injury.
Nursing Interventions
Upon recognizing the residents suicidal risk factors in this case, it is imperative that the
nurse monitor her resident carefully with frequent visits throughout the shift. Keeping the
resident under direct supervision at all times would be ideal, though not cost-effective

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(Sakinofsky, 2014). When there is significant risk of self-harm, a high level of surveillance is
required (Sakinofsky, 2014). Lieberman, Resnik, & Holder-Perkins (2004) recommend that
observation intervals be less than 15 minutes apart so as to reduce the potential for suicide until
the resident is no longer a high risk. What may seem intrusive to nurses, hospital patients
describe as feeling safer and more hopeful when staffinteracts therapeutically with them
(Sakinofsky, 2014, p. 135).
Another intervention for this resident is to ensure her environment is kept clear of any
items that may be used to cause injury to her. Belongings can be kept in a safe, locked place but
safety checks of the residents area should be continued on each shift for the entire time the
resident is in this mental state. Podgorski et al. (2010) call this decrease access to lethal means
whereby safety is the priority. Sakinofsky (2014) goes further to list specific items to be
removed: belts, shoelaces, safety razors and drugs that may be used for an overdose. Other items
that may be used to hang from doors, hooks, handles, or windows such as sheets or towels would
also be removed to protect the resident (Sakinofsky, 2014).
Lastly, detailing commitment to provide consistent support to the resident throughout
their treatment would help considerably, especially if she lacked a family support system.
Beginning with daily introductions, interacting with the resident regularly, will help them to
understand that it is not the end of the world. Building a therapeutic relationship with the resident
is using a psychodynamic approach. This will result in improved depression, hopelessness, and
self-esteem (Boltz, Capezuti, Fulmer, & Zwicker, 2012).
In summary, nursing is more than just learning skills and duties. The ability to prioritize
details: signs, symptoms, and conditions are a significant part of todays healthcare. The scenario
discussed in this paper consisted of a client with multiple co-morbidities; however, the priority
was determined to be psychosocial. By understanding the significance of each clinical
manifestation a patient presents with, one is able to ascertain the nursing priority with more

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clarity. In future, to be successful, nurses we will need to utilize critical thinking, problemsolving, and decision-making skills to their fullest. It is only through hard work, experience and
dedication that nurses can develop into effective RPNs.

References
Boltz, M., Capezuti, E., Fulmer, T., & Zwicker, D. (Eds). (2012). Evidence-Based Geriatric
Nursing Protocols for Best Practice, 4th Edition. Springer. Retrieved from
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c20%7c%2fbookdb%2f01515493%2f4th_Edition%2f4%2fPG
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College of Nurses of Ontario. (2009). Professional Standards, Revised 2002. Retrieved from
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Jancin, B. (2014, May 1). Elderly suicide prevention: focus on housing transition. Family
Practice News, 44(8), 16+. Retrieved from http://go.galegroup.com.rap.ocls.ca/ps/i.do?
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%7CA369220836&v=2.1&u=humber&it=r&p=AONE&sw=w&asid=b3d49f529b2fa4f0

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Lieberman, D., Resnik, H., & Holder-Perkins, V. (2004). Environmental risk factors in hospital
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Osgood, N., & Brant, B. (1990). Suicidal behavior in long-term care facilities. Suicide and Life
Threatening Behavior 20: 113-122.
Podgorski, C., Langford, L., Pearson, J., & Conwell, Y. (2010). Suicide Prevention for Older
Adults in Residential Communities: Implications for Policy and Practice. PLOS Medicine
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Potter, P., & Perry, A. (2010). Canadian Fundamentals of Nursing Revised Fourth Edition.
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Touhy, T., Jett, K., Boscart, V., & McCleary, L. (2012). Ebersole and Hess' Gerontological
Nursing & Healthy Aging, First Canadian Edition. Toronto: Elsevier Canada.
Wood, S., Wood, E., Boyd, D., Wood, E., & Desmarais, S. (2011). The World of Psychology:
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