Prioritizing Patients - Please Help!

Ivanna_Nurse, BSN, RN · Dec 14, 2009

If you polled all of allnurses, you may get a different order and rationale for all of them With that being said, obviously you have put some thought into it already.

So me personally, I would eyeball ortiz quick, check pain control, bleeding vs assessment.

def see smith next...do a quick focusesd assessment

Douglas next, head to toe

Stick my head in on Linden, see if she looks alright.

Return to Smith to finish the head to toe.

Recheck ortiz for bleeding vs, etc.

Is this the way everyone else would answer, probably not. Will there be something that arises that changes this plan? Absolutely. Would I answer the same next week? Bet not.

If you can support your rationales, and justify the Whys, you'll do great! Good luck :) Ivanna

sblivefree · Dec 14, 2009

Thank you!!!!!

PostOpPrincess, BSN, RN · Dec 14, 2009

Smith first. That B/P is UNACCEPTABLE and doesn't belong there. She needs to be on more than q8 hour labetolol.

Linden. Did she get some sort of anti-pyretic? What is her temp now?

Ortiz. Quick check of post op status. Pain, vs, breathing, urine output. (most tend to be very dehydrated after surgery.

Douglas. She seems to be the most stable at this point.

Emergency RN · Dec 14, 2009

LOL, homework questions, I love it...

Your most important priority is always the one that can die on you when your back is turned; hence:

1) Smith - this one's a no brainer, clinically the most precarious, with the one disease (Pregnancy Induced HTN) there are two children's lives at high and imminent risk of death. This is frankly, your ICU Sword of Damocles patient. If teen mom takes a turn for the worst (stroke, MI, etc) they may need to crash section her and pull that baby out at a moment's notice. Remember, the only thing that helps pre-eclampsia is delivery (and I don't mean pizza). Consider this one your continuous On call patient to the OR. Monitor patient's Vital Signs, gross neurological and cardiac status, lung and heart sounds (eg. an s3 may signal impending left ventricular failure) fetal heart rate, ensure that her IV site remains patent as both she and her baby could die without her IV LABETALOL.

2) Ortiz - Major abdominal surgery and only 2 hours post op, this is a potential bleeder. Check vital signs, ensure she knows how to use PCA, and check that alarm parameters and volume are set loudly on your pulse oximeter. People don't appreciate this little tiny finger wonder but this is the machine that is going to tell you if her heart rate goes up, a potential sign that she may be compensating for a dropping blood pressure; or if she stops breathing and O2 sat drops. So the one machine can provide valuable clues to both your circulation AND respiratory functions. Finally, ensure that she has IV access, check her hemoglobin, hematocrit & coagulation, and ensure that the BLOOD BANK has at least 2 units still on hold for her.

3) Douglas - Premature rupture of membranes at 28 weeks means that the fetus is viable. The patient may go into premature labor, or the fetus may suddenly be at more risk. This is the same as Smith but without the hypertension. Hence, there are two lives in the equation here, but really only one at risk (the fetus). Again, they may need to crash section her and pull that baby out at a moment's notice. Monitor patient Vital Signs, fetal heart rate, contractions. She's another on call to OR at a moment's notice; warn the patient to call you immediately if she feels the onset of contractions or abdominal pain.

4) Linden - Still febrile but only day # 2 of Antibiotics, so that isn't all that unusual. She probably needs an antipyretic, but shes at almost zero risk of dying so she can be absolutely last. Monitor Vital Signs, ensure that she is drinking plenty of fluids and has a urine output.

Good luck.

Elvish, BSN, DNP, RN, NP · Dec 14, 2009

Personally, I'd go see: Ortiz, Smith, Linden, Douglas - but you could also make a good argument (as JoPACU and Emergency have done) for seeing Smith first.

Ortiz I'd go see first briefly - quick check of breathing and O2 sat (morphine PCA)

Smith - because that BP is WAY too high, and would assess for other sx of pre-E (epigastric pain, blurred vision, HA). If she's 16, it's likely pre-E instead of gestational HTN but the 24-hr urine will tell that,and I hope she's getting HELLP panels at least q6.

Linden - check pain and recheck temp. That temp is high, but I wouldn't be terribly shocked about someone w/ bad PID having that temp on less than 48hrs of abx.

Douglas - 4 days post ROM, no temp. If she's not contracting she can wait. We keep PPROM patients for weeks and months at a time if they are stable.

If Smith's fetal monitor strip looked bad, or Douglas started feeling bad, or Linden showed sx of septic shock (say that 3x fast), that order would be subject to change. I do have to say, pre-E folks are my least favorite antepartums to take care of because they can go from fine to HELLP in a matter of hours.

I'm interested in seeing what others would say.

PostOpPrincess, BSN, RN · Dec 14, 2009

Smith first. That B/P is UNACCEPTABLE and doesn't belong there. She needs to be on more than q8 hour labetolol.
Linden. Did she get some sort of anti-pyretic? What is her temp now?
Ortiz. Quick check of post op status. Pain, vs, breathing, urine output. (most tend to be very dehydrated after surgery.
Douglas. She seems to be the most stable at this point.

This is cool on the different takes...let me give you my rationales....

1. Smith - no question. She could stroke, seize, she needs to go on MgSo4 and needs to be watched. Basically with that BP, the baby has NO perfusion...

2. Linden - fever is not unusual, but still would want her comfortable. I want to know if the fever spiked. If so, is she on the right abx to avoid sepsis? or is there something else going on?

3. POST OPS should have a PARS score of 9-10 before coming to the floor. I guess coming from the Post op/PACU area the patient has to be incredibly stable before coming to the floor. When I transfer at that point, patient is very, very stable...and has no issues. Potential is there..but she could easily be number 2 r/t PCA and the types of narcs she got and amount. Patient is on continuous monitoring so I might even make it first should there be issues. At this point, I'd follow policy and check on her FIRST...but that would be a toss up. If she is 100% and pain is okay....not enough info....

4. Is stable. PROM at 28 weeks, unremarkable.

If there more info, I would probably change '#3 to #2, or keep the same.

ldcmw1 · Dec 16, 2009

Smith sounds like she should be a one on one!!! She is sick, sick, sick!!!! Teen 1st pregnancy!!! High Risk for pre-clampsia and with blood pressure's that high she could stroke out!! Nothing is said about her lab results on admission? I have rarely ever had a patient with blood pressures that high and I've been a labor and delivery nurse for 12 yrs. She would be on Magnesium Sulfate where I work!!! This assignment is ridiculous!!! Anyway I know this is hypothetical but she would be #1 to see. Check her BP, Neurological status, edema, reflexes, does she have epigastric pain, fetal status, urinary output. Has she been started on steroids for fetal lung maturity?

#2 Ortiz, 2 hours post-op, check bleeding (at dressing site and lady partslly), o2 sat, lung sounds, pain assessment, urinary output, vital signs. Check PCA with another RN against orders! Does she have pneumatic teds on.

#3 Linden what has her temp been? What antibiotics has she been on? Is she in pain has it recently gotten worse. When was the last time she received an antipyretic? Lab results? Is she getting plenty of fluids?

#4 PPROM, she seems pretty stable. Take vital signs, has she felt baby move, is she having pain or contractions? How much fluid is she leaking? I would want to know about her latest ultrasound(how much fluid does she have, position of baby). Have her call you if she feels pain, ctx, decreased fetal movement, bleeding, anything coming out of the lady parts.

sblivefree · Dec 16, 2009

Thank you all for sharing your thoughts on this and allowing me to see the situation through your eyes. Being able to follow the thinking processes and rationalizations of actual nurses really helps solidify the many elements of prioritizing patient care. I've learned more from y'all over the past few days than I have learned from the textbook all semester!

Here's an extension of the previous scenario if anyone feels up to solving more puzzles. Since it's finals week, I haven't had a chance to work on yet, but am going to work on it tomorrow afternoon after my pharm exam & will post what I have then. Am gonna try & squeeze in a couple hours of sleep now. Goodnight :)

3.) Ms. Ortiz has orders to ambulate 6 hours post-op. Four hours into your shift you go into her room to start the ambulation process. You find her sleeping. When you wake her, she lifts her head off the bed, looks at you, mumbles about her pain and falls right back to sleep. Her respiratory rate is 14 breaths/min, O2 saturation is 96% on 2L by NC. She rates her pain a 9/10. She complains of severe dry mouth, her lips are cracked even though her family member is wetting them with a wash cloth. Her PCA is set at 1mg Morphine q 6 minutes on demand. She has made 10 demands for morphine in the last 12 minutes. She has on bilateral sequential compression devices (SCDs).

Priority nursing diagnosis?

priority nursing interventions?

What other assessments would you make at this time?

What is your nursing plan related to the order to ambulate Ms. Ortiz?

4) As you are calling the resident on call to report on Mrs. Ortiz's status, your patient care technician tells you that Ms. Douglas is feeling some cramping and has had a small gush of clear fluid.

What do you do?

What are you going to do to see both of these patients receive immediate care/assessments?

ldcmw1 · Dec 18, 2009

Mrs. Ortiz - Where is the pain? Is she bleeding. Obviously she is not going to get up to ambulate yet. The dry mouth has me stumped but I thought I remember it could possibly be a side effect of having a morphine PCA. O2 Sat is still 96% and there is no previous report of what it was before or respiratory rate was before that so how do you know her condition is worsening without that information. The resident should come and see her.

Ms. Douglas - I would report to the resident her cramping and when you got off the phone with him put her on the external fetal monitor. As far as the gush of clear fluid that isn't so alarming. It isn't blood tinged or green and is normal if she is ruptured and cramping.

CMCRN · Dec 21, 2009

I think this is an impossible assignment. In California it is definately out of ratios! What position is the ruptured 28 weeker? If baby is any position but vertex, in my facility, she requires continuous fetal monitoring. As does the preeclamptic, and to add a fresh post op on top of that... I'de be on the phone to my charge nurse, while doing everything that everyone else suggested above.

sblivefree · Dec 21, 2009

It is certainly comforting to know that I am not completely inept & that this assignment is, in fact, kinda ridiculous. I posted all of the info on each patient that we were given.

I had to turn in the first part of the assignment & prioritized patient care as follows: #1 Smith, #2 Ortiz, #3 Douglas, #4 Linden.

Apparently the "correct" order is #1 Ortiz, #2 Smith ,#3 Douglas , #4 Linden. my prof docked me a good 14 points

It still makes more sense to me to check in on Smith first. The second part of the assignment is due tomorrow & I'm still not sure how I'm going to answer them. I have a few hours yet....

Thanks again for everyone's help- it is greatly appreciated!