Non urgent activities that relieve symptoms, promote healing and prevent complications
Third Priority
Activities addressing a patient's discharge
Fourth Priority
What are the First Priorities?
(10)
Airway compromised
Choking
Impaired gas exchange
Cardiac arrest
Shock
Hemorrhage
Unconciousness
Unresponsive
Mental status change
Seizures
What are the Second Priorities?
(11)
Acute pain
Acute urinary elimination
Diabetic needing insulin
Increased BP need PRN meds
Abnormal labs
Protection from injury & infection
Life saving monitoring/equipment
Monitoring for prevention of sensitive nursing outcomes
Ask for assistance
2 people transfers & turns
Moving a heavy patient
What are the Third Priorities?
(6)
Routine meds
Nutrition
Ambulation/positioning
Monitoring for medication side effects
Teaching
Plan of care
What are the Fourth Priorities?
(3)
Discharge teachings
Arrange for equipment/supplies at home
Follow up appointments
The CCU notifies you a patient on telemetry went form NSR to A-Fib.
Second Priority - An untreated med problem needing immediate attention
The morning labs indicate a patient with a heparin infusion has a PTT of 80.
Second priority - monitoring for prevention of nursing sensitive outcomes
The patient with a small bowel obstruciton continuies to have N/V unrelieved by medication given one hour ago
Second Priority
A newly-diagnosed diabetic patient, discharhed this AM, is having difficulty drawing up insulin.
Fourth Priority - Discharge teaching
A patient who recently suffered a stroke needs assistance eating lunch.
Third Priority - Nurtrition
An obese patient with right hemiparesis needs to get up in a wheelchair
Second Priority - 2 person transfer/move heavy patient
Elderly famale patient with chronic brain syndrome is crying out for help and attempting to get up.
Second Priority - protection from injury
A patient reports pain and swelling at an IV site. The IV site is to be discontinued after this infusion.
Second Priority - Protection from injury/infection
A 72yo post-MI patient is going home after lunch. He lives alone in an upstairs apartment.
Fourth Priority - arrangement for equipment/supplies for use at home
The postop cholecystectomy patient is having chest pain with dyspnea and diaphoresis.
First Priority - Respiratory, impaired gas exchange
The patient with an O2 sat of 91% on 3L/NC needs I.S. teaching.
Third Priority - Teaching
Which of Mr. X's needs should the nurse address first?
A. Shortness of breath
Which of Mr. X's needs should the nurse address second?
A. IV out
Which of Mrs. Y's needs is a first-priority need?
D. Blood sugar >400mg/dl
Enjoys getting up early and going to bed mid-evening; experiences greatest energy levels in the early part of the day
Early bird time style
Likes to sleep until mid-morning and feels most energetic in the mid-afternoon or evening
Owl time style
Likes to do one thing at a time; deadlines and adherence to well-thought out plans are important; finds interruptions to be irritating; personal space is significant.
Monochronic Orientation
Can do many things at once and is easily distracted; tolerates interruptions easily and can change plans readily; deadlines are goals but not absolute
Polychronic Orientation
Approaches time with logic and orderliness; structures time in minutes and hours; schedules activities in time segments and carries them out in an ordered sequence; likes to know the rules and play by them; usually meet their own goals; may elect to work at the expense of fun, play, and other creative and relaxing activities
Left brain dominant
Resists rules and schedules; prefers looking at a project as a whole and completing it in their own way and time frame; are creative and flexible thinkers; may not meet needed completion times
Right brain dominant
Which new patient should the nurse see first?
1. Diagnosis of alchohol abuse with impending DTs
2. Newly casted fractured fibula reporting pain
3. Scheduled for AM nephrectomy.
4. Appendicitis with temp. 101.2
1. Diagnosis of alcholol abuse with impending DTs
After receiving report, which activity has top priority?
1. Assessing a newly admitted pneumonia patient
2. Giving morphine to a fresh post-op patient
3. Preparing to give A.M. medications
4. Reviewing patients’ Plans of Care
1. Assessing a newly admitted pneumonia patient
Which action by the nurse will best decrease workplace interruptions?
1. Closing the patient’s door when entering room
2. Documenting in a secluded area
3. Waiting until after the physician rounds to complete assessments
4. Telling patients the unit is short staffed
1. Closing the patient’s door when entering room
Maslow's Hierarchy of Needs
Physiologic
Safety
Love and Belonging
Self-esteem
Self-actualization
The need to succeed, need to belong and need to control are what theory?
McClelland’s Trichotomy of Needs
Which theory uses the factors of intrinsic & extrinsic?
