PCU/ICU Prioritization Tips

[MCS,RN]

hello all - i'm a new bsn graduate in the process of applying to a critical care internship, as my senior practicum with within an icu and i fell in love with it.

part of the online application for the critical care internship involves responding to a scenario and listing out how i would prioritize care for four patients. like most hypothetical prioritization questions, not nearly enough information is provided on each patient for me to feel confident about my selection. prioirtizing is one of my biggest weaknesses right now and one of the things i'm hoping the internship will help me gain a better handle on.

if you happen to have some free time, i would greatly appreciate the input from some experienced rns. i don't want anyone to answer the problem for me, but i'd just like to know if you think i am on the right path.

here is the scenario:

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you are working your first week of night shifts on progressive care unit. you have received a report on four patients, and are prioritizing and organizing your plan of care for the night.

your patients include:

1. 52-year-old male who is six hours post ptca (percutaneous transluminal coronary angioplasty) with two stents placed in his lad (left anterior descending artery)
   
2. 83-year-old female who just received a permanent pacemaker for third-degree heart block
   
3. 34-year-old female type 1 diabetic recovering from dka (diabetic ketoacidosis). she is still on an iv insulin drop, and was transferred out of the icu earlier in the day
   
4. 78-year-old male in for chf (congestive heart failure) exacerbation
   

suddenly, you hear a three-star alarm on the central monitor. you quickly see it is your chf patient and the rhythm appears to be asystole. upon entry into his room, you find everything a mess. patient is trying to get out of bed, his oxygen is off, his iv is out and he is bleeding all over his gown and bed sheets. you see that all of his telemetry leads are off, his oximeter is off and he is pulling at his foley catheter while yelling he needs to go to the bathroom. between every two or three words, patient pauses for a labored breath and you can hear him audibly wheezing from across the room. his frail little wife is crying while attempting to quiet him down and keep him in bed.

in detail, explain your priorities and describe your interventions for this group of patients.

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i'm leaning towards prioritizing care as 4, 1, 2, 3. here is the rationales for this ordering:

patient number 4, the 78-year-old male in for a chf exacerbation, is my top priority for this group of patients because he is currently experiencing airway and breathing complications. patient number 1, the 52-year-old male who is six hours post ptca with two stents placed in his lad, is my second priority because of the risk for impaired cardiac and cerebral tissue perfusion should he experience a stroke. patient number 3, the 34-year-old female type i diabetic recovering from dka, is my third priority because she will continue to require frequent cbg checks and insulin drop rate adjustments until her blood glucose has been returned to between 70 and 130 mg/dl. patient number 2, the 83-year-old female who just received a permanent pacemaker for third-degree heart block, is last on my list of priorities at this moment. though she is at risk for decreased cardiac output should the pacemaker malfunction as well as at risk for infection with the risk factor of an invasive procedure, the patient's primary concern at this time is likely acute pain at the surgical site.

i can come up with the individual care plans no problem but i keep second guessing my prioritization order. should the diabetic have higher priority over the ptca post-op? thank you in advance for any input or words of wisdom you might be able to provide!

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[mlbnocnurse]

Based on the very limited amount of info that you have been given, I would say that I would do exactly what your answer was. I find it hard to believe that prioritization is something that you need to work on so much. You have responded to the limited info very logically, you are able to state your rationales very clearly. Great job!!

[gwapo]

I would agree with your prioritization. But i think in the real world, after i get PT #4 settled, i would see PT #3. For sure by the time you get out of PT4's room, it's been 1 hour since her sugar was checked (assuming BS are checked hourly). i would see her and check her blood sugar and make sure the IV pump was set right. Then I would see PT3,like you saud, she maybe having some pain. she's older, she might also need help going to the bathroom with her arm in a sling. i would see PT1 last. it's been 6 hrs since the procedure, sounds like he's doing ok otherwise he will be on the call light if he had chest pains again. if he needs to pee, i am sure the urinal is right beside him. lol

[gwapo]

I can come up with the individual care plans no problem but I keep second guessing my prioritization order. Should the diabetic have higher priority over the PTCA post-op? Thank you in advance for any input or words of wisdom you might be able to provide!

Pt#3 is on an Insulin gtt. I would see her first. PT#1 is not on anything. if he was on Dopamine or other gtts with the sheaths still in, it will be a different story.

[dorie43rn]

I agree 4 would be first due to his acute condition, but I would see the diabetic next. She came from ICU, and with an insulin drip, she could be laying in the room unconcious from low blood sugar. I would see 1 next, and 2 last.

[CNL2B]

I mostly agree with all of the above, but everyone so far has failed to mention that the PTCA patient in bed 1 needs to be looked at to make sure he isn't developing a groin hematoma. 6 hours post-plasty in a lot of institutions is either just off bedrest or not quite off bedrest yet -- you would want to check him first to make sure he was OK to get up. After the patient that is freaking out, depending on what time the diabetic patient's blood sugar was due to be checked, I might see him first. Probably before your shift even started you could review your patient charting system and look at your last few blood sugar checks, find out if it is trending up or down, what the insulin is running at, and what time your next check is due. Depending on where you were at it might not be as big a priority to see her first.

[EmilyCCRN]

Just my , but a patient who is 6 hours post-PCI (percutaneous coronary intervention - 'PTCA' is not used very much anymore) should be pretty darn stable, especially compared to the other patients in this scenario. The patient should be on hourly groin/vital sign checks and could very well be off bedrest at this point, too.

I would see patient #4 first, then 3, 2, and 1. Here is my rationale:

#4 is going to wind up coding if we don't address his breathing and IV situation right away. And I'm a cardiac RN through and through - get that guy back on the monitor STAT!

#3 needs a glucose check to make sure she's not tanking. She just came from ICU today, so it sounds like her sugars aren't very stable yet.

#2 received her PPM for CHB, so we need to check on her for three reasons: she has a fresh surgical incision following a procedure where a major chest vein was punctured, she probably received moderate sedation during the PPM insertion so her LOC should be assessed, and she received the PPM for a life-threatening dysrhythmia, so she's probably pacer-dependent. Let's make sure she isn't unconscious or bleeding out and that her pacer is still firing (which would be 'unconscious' for a different reason ). Also let's give her a quick reminder to keep her left (or right) arm immobile to prevent the lead(s) from being dislodged from her heart muscle.

#1 (see above). This guy should be relatively stable since it has been six hours post-procedure.