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Discussion

Priority-setting questions are fun

All, I got this question as a PM from a student who wanted to know the justification for the answer to an exam prep question. This is a slightly longer answer than I sent her because I was on a mobile device then and now I'm right here at my big desktop, but it's got the same information. She wrote:

Your patient is receiving blood transfusion and complains of itching and hives are noted. place the following interventions in the priority order and the correct answer is below:

1)stop blood transfusion

2) maintain the infusion with normal saline

3)assess vital signs and airway

4)notify the primary care provider

my question is why is 'maintain the infusion with normal saline' more important than assess vital signs and airway? is it because hemorrhage has higher priority than airway and vital signs?

thank you so much :)

The answer is in part because this is one of those questions that tests several different kinds of knowledge and critical thinking.

I think we can agree that pretty much everybody will say, "Stop the blood, fergawdsakes!" is the first thing to do, because that stops the ongoing opportunity for harm. And pretty much everybody will agree that you need to take VS and notify the provider after the VS, so you have some data to share. So what the heck is that "keep running NS" doing in there? And why is it more important than VS and the phone call?

This is where they want to know if you know that blood is ALWAYS (or so often that it's an extremely rare circumstance that it's not) given with a NS in a Y set-up. So at the same time you're turning off the blood, the NS is right there.

Why would you want to be sure it's running? The question also wants to know if you know that if your patient has a really bad reaction, like anaphylaxis, you're (and he's) going to be really sorry if you don't have a functioning IV in place because it's really hard to start an IV on somebody with no arterial BP and no venous return to fill up the veins ...and voila, there's your saline, already running nicely for the rapid-response team.

So: you would run the saline immediately to preserve the line (patient safety), then take your VS and call the provider (and it doesn't give you this choice to throw into the mix, but you would not leave this person alone-- call for help, or have somebody else make the phone call).

Fun question! :anpom: More?

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    OK I liked that, but I always wondered with the "Y" tubing that is made specially for blood transfusions, yes your saline is hooked up and you run the line with the saline and then clamp it and then run the blood. However, if there is a transfusion reaction, you stop the blood obviously and then there is a bag of saline hanging there, but to clamp the blood and let the saline run means that the blood that is in the tubing will still get to the patient.

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    OK I liked that but I always wondered with the "Y" tubing that is made specially for blood transfusions, yes your saline is hooked up and you run the line with the saline and then clamp it and then run the blood. However, if there is a transfusion reaction, you stop the blood obviously and then there is a bag of saline hanging there, but to clamp the blood and let the saline run means that the blood that is in the tubing will still get to the patient.[/quote']

    You can detach the line briefly and flush it if there's more than a few cc's in your downstream tubing. If it's a central / large bore line you could even aspirate back. If you've had a reaction already, a cc or two won't make much difference (adult-sized patient).

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    I believe you'll have to hang a whole new setup. It's been such a looooong time but I think all the equip with blood bag goes back to the lab.

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    Yes, more, please; harder ones, please. Thank you.

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    Yes, more, please; harder ones, please. Thank you.

    Hey, I didn't write it, I just gave my opinion on it. ;)

    Students: What head-scratchers have you come across? Tell us what you think, and we'll help you see how to think about these sorts of conundrums.

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    What is the real priority? Naturally you will stop the blood immediately, then start the saline. It only makes sense.

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    What is the real priority? Naturally you will stop the blood immediately, then start the saline. It only makes sense.

    That's true. But if you read the question, she was asked to prioritize ALL FOUR actions, meaning, put them in order of priority-- which to do first, second, third, and last. Those are the first two, obviously. Her question concerned the decisions on what order to implement the remaining two.

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    Hey Grn Tea, the kind of priority questions that trip me are those ask to prioritize patients according to who you will see first and last. Case in point: it's 7 am and you have received report on the following pts, arrange them in the order in which you will see them:

    a) pt has been receiving blood transfusion since 3 hours earlier.

    b) pt needs a rapid insulin before breakfast arrives

    c) pt is due for discharge and needs teaching reinforcement before discharge

    d) pt is on prn pain medication, of which last dose was given at 0430

    There was a 5th pt but I forgot the scenario. Anyway, I knew the discharge pt would be seen last. Then I was stuck as to who to see first between blood transfusion and insulin pts. I got the question wrong! Your help will be very much appreciated!

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    I am sorry not to have seen this earlier, because these questions are classics...and because you will see something very like them many times when you come in to work.

    In my opinion, the insulin comes first, because the consequences of missing that are more serious than the blood. If the blood has been running for three hours with no adverse effects, you can safely put it aside for long enough to do the insulin. Then, though, this question wants to know if you remember that blood has to be given within four hours of leaving the blood bank's refrigeration, so if there's a problem slowing it down you want to fix that soon.

    The prn pain med pt-- the question does NOT say s/he is asking for more now. If s/he were asking for more now, it would be insulin, pain, then check blood. If not, then put off your pain assessment until your morning checks.

    What did they tell you the answer was?

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    It's funny you posted this. I work with a lot of new grads and they struggle with priority setting. I know it takes time to learn.

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