Priority Help!

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You, an RN, are assigned the following patients for total care today. Report is over at 0720. Prioritize these four patients and provide rationale for your decisions.

401 Mr. A: 65 year old, same day surgery admission at 0630 for a herniorrhaphy this morning. He's been NPO since midnight. The admission is complete and the OR permit is signed. His temp was 97.8, pulse 78, respirations 20. BP was 132/68. Pre-op med is due at 0800.

402 Miss B: 71 year old, diabetic with a left femoral-popliteal bypass, first post-op day. Temps during the night were 99.2 and 99, pulses 88 and 84, respirations 20 and 18. BPs142/88 and 144/88. Pedal pulses are 80 and 84 on the right and not palpable on the left. The left foot is somewhat cooler than the right, but there is good capillary refill. Her dressings are clean and dry. She has an IV of D 5 1/4 NS at 100 ml/hr with 320ml to go and remains NPO. She has a foley that drained 125 ml of concentrated urine since midnight. She is on sliding scale insulin. Her glucometer check was 240 this morning, and she got 10 U of regular insulin. She has an IVPB antibiotic at 0800.

403 Mr. C: 42 year old, had a gastric resection and returned from PAR at 0430 yesterday (27 hours ago). He has a Salem sump pump on low intermittent suction that drained 675 ml of bloody/green drainage during the night. He has an IV of lactated ringers at 150 ml/hr with300 ml to go. He has 2 units of blood on call. Hourly BP's have ranged from 112-120 over 64-70. 0600 BP was 112/64. Pulse has been 80-98 and was at 98 at 0600. He was cathed for 250 ml at 0400. He's been turned q2h. He coughs and deep-breathes poorly. He had Demerol 75 mg IV at 0345. His dressing had a large amount of sero-sanguinous drainage when it was changed at 0400.

404 Mrs. D: 59 year old, with lung cancer, had a scalene node biopsy yesterday afternoon to check for metastasis. She is to be transferred to her home by ambulance this morning at 0830. She has 0800 and 0900 meds. She had a poor night, developing a new onset of SOB with O2 sats at 0200 of 94 % and at 0600 of 90%. She was placed on O2 at 2 L at 0200.

Okay so here goes nothing...

1. Mrs. D in room 404 - Pt has a new onset of SOB and O2 sats have been dropping. I would consider her first priority due to breathing.

2. Miss B in room 402 - Pt is lacking peripheral pulse after surgery is displaying signs of decreased circulation. Also, foley has only drianed 125 mL in about 7 hours, definitely having perfusion issues. Temp also elevated.

3. Mr. C in room 403 - Pt's vitals appear stable. Will probably need dressing change and possibly pain meds.

4. Mr. A in room 401 - Pt is stable and just waiting for pre-op med and OR.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I agree with seeing the SOB first and be sure she is OK.

I would probably double check on the post op gastric by pass they haven't been medicated since 0330 not coughing well and having a ton of drainage. His BP is trending down some and the heart rate is trending up...indicating he may need more volume or transfusion.

I would then check the post op Fem Pop. The temp of 99 is probably inflammatory response and normal for post op...although her output isn't great her vitals are OK.

The preop would be last.

right or wrong that is what I would do.

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Thanks for the quick reply! Definitely waffling back and forth on the middle two pt's.

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I would probably do it as you stated. I believe your reasoning is also pretty correct. The lung patient first(impaired gas), the fem-pop second for sure(perfusion), the resection third(fluid/electrolytes,possible pain)and last one is self explanatory.

I dont really thing 675 over 8-12 hours is "tons" especially when the are receiving IVF per hour double what they were putting out.

Fem-pops and other vascular interventions have a potential to go bad fast. Retro peritoneal bleed and hematomas.

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I know this is a school exercise and this option probably isn't open to you, but two of those folks could be in trouble enough that you won't be done with them by the time the preop med is due. I might see if someone can take a quick look at him and make sure he's still fine and give him his preop so he won't be delayed when OR calls for him.

You wouldn't expect somebody with a fem-pop bypass to have awesome pulses and perfusion. Usually when you have bad arteries in one place you have them all over; if capillary fill is ok, that's probably the best you can expect if it's no worse than it was preop. This might also be why her dehydration is a concerning feature about her lousy u/o. You don't want her losing renal function over time, since she is at increased risk to do that.

The lady c the scalene node bx is sliding down and you should be thinking that she isn't getting in any ambulance to go home until her resp status is clarified (as in, why is it declining) and she gets perked up.

Gastroguy is looking reasonably acceptable, but has potential to decline if you don't work on his mobility and coughing/deep breathing. That's why he's here. Somewhat bloody NG is expected, but you want to be sure that doesn't get bloodier and that the blood decreases over the course of the day. And who the heck gives Demerol anymore? Old test bank question. :)

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Specializes in NICU.
And who the heck gives Demerol anymore? Old test bank question. :)

That is what I was wondering. Obviously an old case study book or old(er) instructor that has used the same case studies for years.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I would probably do it as you stated. I believe your reasoning is also pretty correct. The lung patient first(impaired gas), the fem-pop second for sure(perfusion), the resection third(fluid/electrolytes,possible pain)and last one is self explanatory.

I dont really thing 675 over 8-12 hours is "tons" especially when the are receiving IVF per hour double what they were putting out.

Fem-pops and other vascular interventions have a potential to go bad fast. Retro peritoneal bleed and hematomas.

Depends on the facility policy. I know of places that still q 8 hour I/O's so 650 in 8 hours is a lot. I was looking at the vitals downtrend and they are have abdominal drainage as well..
His dressing had a large amount of sero-sanguinous
so more fluid loss...his urine output was only 250....and he hasn't been medicated for pain since 4 am...... The fem pop has good cap refill and a low u/o but ok vitals.

Now I want to know what the school thought

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Specializes in Family Nurse Practitioner.

Remember your ABCs

1. I would for sure see 404 Mrs D with the SOB first. Something could have gone wrong with that biopsy. BREATHING

2. Next I would see 403 Mr C. He has a lot going on. He needs blood and he's bleeding from his incision site and isn't breathing or coughing well. BREATHING + CIRCULATION

3. Then I would go visit Miss B in 402. Her findings are expected with a fem pop. I would go in with a doppler to make sure there is a pulse, but since there is good capillary refill I am not too concerned. The leg/foot is swollen, so it may make palpating a pulse difficult. She is NPO and dehydrated. CIRCULATION.

4. Finally I would see 401, the pre-op patient who is stable.

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Depends on the facility policy. I know of places that still q 8 hour I/O's so 650 in 8 hours is a lot. I was looking at the vitals downtrend and they are have abdominal drainage as well..so more fluid loss...his urine output was only 250....and he hasn't been medicated for pain since 4 am...... The fem pop has good cap refill and a low u/o but ok vitals.

Now I want to know what the school thought

Im sorry, but that is incorrect. Normal NG tube output is 2L or less per 24 hours=333mL per 4 hours, therefore it is not tons.

Plus the fem pop has only voided 125 over 7 hours...not good

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Im sorry, but that is incorrect. Normal NG tube output is 2L or less per 24 hours=333mL per 4 hours, therefore it is not tons.

Plus the fem pop has only voided 125 over 7 hours...not good

You are right...but it is still a loss in addition to the bandage drainage....a loss that the fem pop doesn't have. Is 150/hr sufficient for the patient?

Maintenance fluid requirement

  • 4 ml/kg/hr for first 10 kg of patient’s weight

  • 2 ml/kg/hr for second 10 kg of patient’s weight

  • 1 ml/kg/hr for every kg after that

hummm....I feel the post op bariactric patient is showing hemodynamic signs of decompensation with trending vitals. The Fem Pop saw staff this morning with her insulin administration so I would see the one not seen yet. For me it's a toss up. I would look at EBL in the OR to make a final decision.
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I do not see any trrending down vital signs. Circulation over fluids definitely first IMO

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Specializes in Emergency, Telemetry, Transplant.
I do not see any trrending down vital signs. Circulation over fluids definitely first IMO

The trend is subtle and may be nothing, but his most recent VS reveal his highest HR of the night and his lowest BP.

I am a bit concerned about his poor coughing/deep breathing. I would want to get on him early about using his IS and see if there is a flutter valve (I am thinking of the correct thing, right? ;)) and get those secretions mobilized.

I definitely agree with seeing the scalene bx. first, preop last...I would go with this gentleman before the fem pop.

(and for the record, I don't think he is necessarily a bariatric pt--the OP said he had a gastric resection...this could be for stomach CA or something like that)

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