ATI Priority Setting Frameworks

ATI Priority Setting Frameworks Priority setting- involves the organization of client care such as that the most critical intervention or action is completed first. In a health care facility, the nurse uses priority setting when determining which needs to address first for an individual client as well as when caring for a group of clients and identifying which client to care for first. Maslow’s Hierarchy of Needs- a theory developed by Abraham Maslow, that identifies five categories of human needs, when unmet, motivate clients to take action to meet those needs. The first four levels are considered deficiency needs. Deficiency needs include, security and safety, physiological, belonging and love, and self-esteem needs. The needs located in lower need to be met first, before an individual will attempt to fulfill needs higher in the pyramid. The top level of need, self-actualization, is considered a growth need. Physiological needs- the essential physical needs required for survival. Food, water,air,shelter,sleep,clothing and reproduction. Safety and Security- security of the environment, personal security, employment security; health and property. Love and Belonging- social need. At this level behavior is motivated by the need for social relationships like friendships, family relationships, intimacy, trust, love, affection and sense of connection. Self Esteem needs Two factors motivate the need for self-esteem: the desire to feel good about oneself and having the respect of others. A high sense of self esteem is achieved by having confidence in one’s abilities and achievements, as well as gaining recognition, appreciation and respect from others. When self esteem needs are not met, a sense of uselessness is developed. Self Actualization-refers to the desire for self-fulfillment—for reaching ones greatest potential, whatever that may be. It is the desire to be whatever it is that one wants to be, and to achieve that most that one can achieve. After all deficiency needs are met, individuals strive to reach their fullest potential. They may experience restlessness and unhappiness until they achieve that goal. According to Maslow, very few people are able to reach this state. ABCDE priority framework Purpose is to recognize and stabilize the clients most critical issues first and then move to the next vital system with the goal of improving the clients outcome and providing time to develop a diagnosis. Airway- a client who is experiencing a compromised airway requires immediate intervention to prevent both illness and death. In evaluating the patency of the airway, the nurse listen for breath sounds that may indicated a partially obstructed airway, such as gurgling and high pitched wheezing sounds. Also check the clients ability to talk and observes symmetrical chest wall movement. If the client can speak, the airway is unobstructed. If the client unable to speak, and has absent breath sounds, the airway is obstructed and should be opened using the head tilt, chin lift or jaw thrust maneuver, inserting an artificial airway or suctioning secretions that are blocking the airway. O2 is administered to reach an O2 sat of 94-96% for clients who do not have a hx of COPD. For clients with COPD target O2 Sat is 88-92%. O2 Sat-measure how much O2 is attached to hemoglobin molecules vs. how much O2 remains unattached. Use pulse ox to monitor O2 saturation. Breathing After the clients airway has been established, the nurse assess the clients breathing status. Auscultate the clients lungs; obtain a respiratory rate, including depth and pattern; monitor for central and peripheral cyanosis; and observe for the presence of thoracic wall symmetry as well as the use of accessory muscles during breathing. When obtain resp rate count clients breaths for one minute. Look for equal movement of both sides of the chest (indicates thoracic wall symmetry). Look for accessory muscle use during breathing- occurs when the neck, shoulder, chest and abd muscles are used to accomplished breathing- called increased work of breathing. Check clients ability to speak, a client who is fatigued from increased effort of breathing might not have enough breath to speak. Continuously monitor O2 saturation and check other vitals. A Venturi mask may be needed for the delivery of O2 to maintain therapeutic O2 levels. If client is experiencing respiratory distress, place the client in an upright position to promote lung expansion. Circulation Adequacy of circulation is determined by evaluating a clients BP; capillary refill time; pulse rate, including volume and character; urine output and level of consciousness, as well as by looking for changes in the clients’ skin tone. Manifestations of dec circulation: Skin tone and temp changes decreased level of consciousness prolonged capillary refill time hypotension changes in pulse rate, regularity and volume decreased urine output Treatment for altered circulation depends on cause, but usually includes fluid replacement, controlling bleeding and restoring tissue perfusion. Disability Measuring disability involves determining a clients neurologic status. This includes level of consciousness, response to verbal or painful stimulation and level of orientation. Any impairment in a clients airway, breathing or circulatory function can cause a change in neurologic status, that is why it is important that the nurse complete the ABC assessment before evaluation clietns neurologic status. Exposure The nurse should uncover the client as needed to check the client from head to toe. Check for: internal or external bleeding (e.g., abdominal distention, bruising of the skin) rashes or other indications for allergic reaction or edema Check for manifestation of DVT (warmth, pain, edema of the calf) When applying the ABCDE as a priority framework, you will ensure the client has an adequate airway first, giving second priority to breathing, then circulatory status followed by disability and exposure. The Nursing Process- a four or five step process that guides nurses in prioritizing care for clients. The 5 steps used by RN’s are 1. Assessment 2. Analysis 3.Planning 4. Implementation 5.Evaluation LPN uses a 4 step process 1. Data collection 2.Planning 3.Implementation 4.Evaluation Assessment/Data Collection Used to gather information about a clients status. Nurses gather this information by preforming physical examinations, conducting client interviews, reviewing past medical records and making general observations. Date collected is either subjective or objective. Subjective data consists of the expression of facts from the client or caregiver. Objective data- information that can be seen and measure (vital signs, lung sounds and weight). Analysis Involves the nurse making a clinical judgement regarding the actual or potential health conditions or needs of the client; this judgment is, in turn used to assist in the planning and implementation of client care. A RN (NOT LPN) is responsible for this step of determining the client’s needs. Date collected during the assessment phase is used to form a nursing diagnosis. Planning In planning, the nurse develops evidence-based goals and desired outcomes. Care plans are a client centered and client specific. When developing the care plan the nurse should develop SMART goals- specific, measurable, attainable, realistic, and timely goals. RN is responsible for developing the care plan. Implementation The nurse actively preforms nursing interventions developed during the planning phase. This step includes nursing interventions that are specific to the client such as, pulse ox, administering meds, and providing client education. May involve direct and indirect care. Direct care- nursing care that is conducted under a health care providers prescription. Examples of direct care: administering meds, preforming diagnostic exams and assisting with activity. Indirect care- activities that are preformed away from the bedside such as the documentation of client care. Evaluation- the final step, essential to a positive client outcome. After the nurse has implemented the nursing interventions developed in the planning step, the client is reassessed to determine whether the desired outcome (goal) has been met. If goals have not been achieved the care plan may need to be revised and new interventions, goals and outcomes developed. Safety and Risk Reduction Client safety- the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum. The safety and risk reduction priority setting framework places priority on the situation or factor that places the client at the highest safety risk. Issues that would cause the greatest risk to a clients psychological or physical well being are deemed priority. When a client faces multiple risks the issue that creates the greatest risk is the highest priority. Least restrictive/least invasive priority setting framework assigns nursing intervention priorities based on what is the least restrictive and least invasive for the client. Focuses on using the least restrictive and least invasive method to resolve a problem while maintaining client safety. Example: Prior to applying restraints toa client the nurse should attempt other preventative measures, when possible, to avoid the use of this last resort intervention. Have a staff member or family member sit with client. Use of bed or chair alarms. If a client experiences incontinence after a surgical procedure, the nurse should implement a toileting schedule and teach Kegel exercises to help the client regain bladder control rather than inserting a urinary catheter. Survival potential framework is used based on doing the most good for the maximum number of clients at a time when health care resources are limited due to a large number of injuries. When using this framework at a mass causality incident, responders perform triage to identity the most severely injured clients with the highest survival potential. Primary goal of triage is to classify clients into categories with triage tags, colored tape or other methods and then transport them away from the incident to an area in which more thorough care can be provided. Triage uses four main prioritization categories based on injury severity: emergent(red)- clients who must be transported away from the scene immediately. Have life threatening injuries but high probability of survival with treatment. Ex: a client who has a major hemorrhagic wound or a client experiencing chest pain. urgent or delayed (yellow)- clients who have serious injury that does not pose an immediate threat to life. Ex: a client who has an open fracture without major bleeding. Have an injury or condition that requires treatment within 30mins – 2 hrs. nonurgent or minimal (green)- clients who only have minor injuries. Clients must be able to wait for treatment unit all other clients have been treated. “THE WALKING WOUNDED” Ex: sprained fingers or minor cuts. Treatment can be delayed up to several days to allow time to care for others with more serious conditions. expectant (black)- includes clients who are either deceased or not expected to survive. Client might be unable to breathe spontaneously or might have severe damage to multiple body systems. Not transported to medical facility, they are provided with comfort measures and allowed to die. Might be assigned blue tag if still alive. Additional Priority Frameworks Acute > Chronic Urgent > Nonurgent Unstable > Stable Critical client care needs require the nurse to intervene immediately to prevent the client from deteriorating. (Respiratory difficulty, chest pain, change in neurologic status) Urgent client care needs are identified when the client could suffer mild harm or discomfort if there is a delay in addressing the clients needs. (post op pain) Route client care needs include tasks such as administering routine meds and preforming required shift tasks. (routine vitals, daily physical assessment) Extra client care needs involve activities that are not essential to client care but promote comfort. (Providing warm blanket, combing hair) Acute vs Chronic Priority Setting Framework Acute conditions- a state in which manifestations are severe, appear suddenly and can worsen rapidly. Acute conditions are prioritized over chronic conditions. Example of an acute condition: asthma attack or exacerbation. Chronic conditions progress ad worsen over a prolonged period of time (chronic emphysema). Chronic emphysema usually develops after years of smoking and manifestations do not become noticeable until 50 % or more of lung tissue has been destroyed. Urgent vs Nonurgent priority setting Framework Urgent needs prioritized over nonurgent. Urgent needs are factors or situations that have a considerable probability of causing harm or discomfort to the client if interventions are not implemented quickly. Example: Answering a bed alarm; if left unattended, a client could sustain a fall. Non urgent needs- low risk needs Examples: MSK conditions, non-allergic itching, and reports of pain with urination. Unstable vs Stable Priority Setting Framework Unstable prioritized over stable. An unstable client has experienced an acute change in condition, whereas a stable client has a condition that changes little over time. Unstable condition examples: uncontrolled bleeding, severe respiratory distress, and frequently changing BP readings. Stable examples: vital signs remain unchanged and within the expected reference range, client who has a mildly elevated BP with history of HTN. Resources allocation- the process of distributing materials, staff or other resources to department or project. Rationing- process in which allocated resources are scarce and there will not be enough to meet all of the required needs. Rationed care is described as care that is left undone, omitted or missed due to limited resources.