ATI Nurse Logic- Priority Setting Frameworks PDF

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ATI Nurse Logic: Priority Setting Frameworks I.

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Priority Setting Frameworks a. Using nursing judgment to make decisions about the order of nursing actions b. Seven Priority Setting Frameworks i. Maslow’s Hierarchy of Needs ii. The Nursing Process iii. Airway, Breathing, Circulation iv. Safety and Risk Reduction v. Least-restrictive least invasive vi. Survival Potential vii. Acute VS Chronic viii. Urgent vs Non-Urgent ix. Unstable VS Stable Findings c. Questions that should be asked i. What client should I see first? The most important assessment findings? Interventions now and can be done later? Proper sequence of steps to perform procedure? What can I delegate? Maslow’s Hierarchy of Needs a. HIGHEST PRIORITY: Physiological Needs: Needs necessary for survival and make up foundation of the triangle i. Oxygenation, Circulation, Nutrition, Elimination, Fluid Balance, Activity and Exercise, Rest and Sleep b. Safety and Security i. Living in a safe environment, adequate income, shelter from environmental elements c. Love and Belonging i. Affection and relationships d. Self-esteem i. SELF RESPECT, personal worth, and social recognition e. Self-actualization

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i. Personal growth, fulfilling own potential Airway, Breathing, Circulation a. PRIORITY of initial assessment b. Critical to survival, alteration in one could indicate threat to life/need for resuscitation c. Airway i. Must be open and clear ii. Patient must need 1. Temporary oral or artificial airway 2. Supplemental oxygen d. Breathing i. Essential for oxygen exchange ii. Respiratory rate within expected reference range iii. Patient might need 1. Artificial ventilation 2. Negative pressure gradient in pleural cavity 3. Chest tube e. Circulation i. Heart rate and blood pressure within expected reference range for adequate cardiac, cerebral , and peripheral perfusion Safety and Risk Reduction a. Assigns priority to the factor or situation posting the greatest i. Safety risk to the client b. SOURCES i. Patients ( confused, immobility) ii. Nurses ( incorrect care performed or timed) iii. Prescriber ( write wrong prescription) iv. Inappropriate use of medical equipment or environment that places hazards in clients path v. Home environment can pose risks for falls ( throw rugs, lack of grab bars in bathroom, and furniture arrangements) vi. Community ( neighborhood and lack of health related resources) c. External: risks in clients environment d. Internal : lab values, vital signs, body organs not properly functioning

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Least Restrictive/Least Invasive a. Priority goes to interventions that are least restrictive and least invasive to client b. Do not put patient at risk for harm or injury c. LEAST RESTRICITVE i. Unauthorized usage of restraints is assault, battery, false imprisonment d. LEAST INVASIVE i. Reduce number of organisms introduced into the body to reduce hospital acquired infection Survival Potential a. Chance client has for survival during mass causality event b. Appropriate use of resources to save greatest number of lives c. CLASS 1 : EMERGENT i. Life threatening injuries ii. Need immediate treatment = chance for survival d. CLASS 2: URGENT i. Serious and extensive injuries ii. Not immediate threat to life iii. Potential survival although treatment is delayed e. CLASS 3: NON URGENT i. Less serious and less extensive injuries ii. Do not pose a threat to life iii. No threat to life even with delayed treatment f. CLASS 4: EXPECTANT i. Injuries are not compatible with life ii. Potential for survival does not exist iii....